Healthcare Provider Details
I. General information
NPI: 1821057779
Provider Name (Legal Business Name): JEFF A BENJAMIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 03/20/2006
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
8170 ROURK ST
MYRTLE BEACH SC
29572-4127
US
IV. Provider business mailing address
8170 ROURK STREET
MYRTLE BEACH SC
29572-4127
US
V. Phone/Fax
- Phone: 843-449-2336
- Fax: 843-497-2505
- Phone: 843-449-2336
- Fax: 843-479-2505
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 2084N0400X |
| Taxonomy | Neurology Physician |
| License Number | 0501 |
| License Number State | SC |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 2023740 |
| Identifier Type | OTHER |
| Identifier State | SC |
| Identifier Issuer | EVOLUTIONS |
| # 2 | |
| Identifier | 01838875 |
| Identifier Type | MEDICAID |
| Identifier State | PA |
| Identifier Issuer | |
| # 3 | |
| Identifier | 1061000 |
| Identifier Type | OTHER |
| Identifier State | WV |
| Identifier Issuer | WORK COMP |
| # 4 | |
| Identifier | 3099820 |
| Identifier Type | OTHER |
| Identifier State | SC |
| Identifier Issuer | GHI |
| # 5 | |
| Identifier | 434035 |
| Identifier Type | OTHER |
| Identifier State | SC |
| Identifier Issuer | ONE HEALTH PLAN |
| # 6 | |
| Identifier | 6906038 |
| Identifier Type | MEDICAID |
| Identifier State | NC |
| Identifier Issuer | |
| # 7 | |
| Identifier | A156 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | NC UHC |
| # 8 | |
| Identifier | 1189849 |
| Identifier Type | OTHER |
| Identifier State | SC |
| Identifier Issuer | FIRST HEALTH |
| # 9 | |
| Identifier | 7251177 |
| Identifier Type | OTHER |
| Identifier State | SC |
| Identifier Issuer | AETNA |
| # 10 | |
| Identifier | 82645 |
| Identifier Type | OTHER |
| Identifier State | SC |
| Identifier Issuer | MEDCOST |
| # 11 | |
| Identifier | 005014 |
| Identifier Type | MEDICAID |
| Identifier State | SC |
| Identifier Issuer | |
| # 12 | |
| Identifier | 0504464 |
| Identifier Type | OTHER |
| Identifier State | SC |
| Identifier Issuer | PHP |
| # 13 | |
| Identifier | 521523 |
| Identifier Type | OTHER |
| Identifier State | SC |
| Identifier Issuer | FOCUS HEALTHCARE |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
