Healthcare Provider Details

I. General information

NPI: 1376075804
Provider Name (Legal Business Name): BENJAMIN PHYSICAL MEDICINE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

373 BLAIR PARK RD STE 206
WILLISTON VT
05495-7998
US

IV. Provider business mailing address

373 BLAIR PARK RD. STE 206
WILLISTON VT
05495
US

V. Phone/Fax

Practice location:
  • Phone: 802-522-9699
  • Fax:
Mailing address:
  • Phone: 802-522-9699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number420010625
License Number StateVT

VIII. Authorized Official

Name: DR. SCOTT EVAN BENJAMIN
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 802-522-9699