Healthcare Provider Details

I. General information

NPI: 1942973680
Provider Name (Legal Business Name): BENJAMIN JON PILGRIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HARBORSIDE DR #104
GALVESTON TX
77550
US

IV. Provider business mailing address

400 HARBORSIDE DR #104
GALVESTON TX
77550
US

V. Phone/Fax

Practice location:
  • Phone: 409-772-2166
  • Fax:
Mailing address:
  • Phone: 409-772-2166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10077028
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: