Healthcare Provider Details

I. General information

NPI: 1669121083
Provider Name (Legal Business Name): BENJAMIN NYE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SKYLINE DR
JACKSON TN
38301-3923
US

IV. Provider business mailing address

6675 HOLMES RD STE 450
KANSAS CITY MO
64131-1173
US

V. Phone/Fax

Practice location:
  • Phone: 928-533-3068
  • Fax:
Mailing address:
  • Phone: 816-276-7600
  • Fax: 816-276-7992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number6043
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: