Healthcare Provider Details

I. General information

NPI: 1235424730
Provider Name (Legal Business Name): J D BENITONE MD FACS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2144 MONROE AVE
MEMPHIS TN
38104-4229
US

IV. Provider business mailing address

2144 MONROE AVE
MEMPHIS TN
38104-4229
US

V. Phone/Fax

Practice location:
  • Phone: 901-274-9046
  • Fax: 901-272-7360
Mailing address:
  • Phone: 901-274-9046
  • Fax: 901-272-7360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY D BENITONE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 901-274-9046