Healthcare Provider Details

I. General information

NPI: 1619938024
Provider Name (Legal Business Name): MID ATLANTIC HEALTH SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 DOCTORS PARK
GALAX VA
24333-2277
US

IV. Provider business mailing address

103 DOCTORS PARK
GALAX VA
24333-2277
US

V. Phone/Fax

Practice location:
  • Phone: 276-236-2947
  • Fax:
Mailing address:
  • Phone: 276-236-2947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057515
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101041026
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001464
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024103947
License Number StateVA

VIII. Authorized Official

Name: ROBERT BENISH
Title or Position: PRESIDENT
Credential:
Phone: 276-236-2947