=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104209758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAN S BENDER MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2015
-----------------------------------------------------
Last Update Date | 07/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6449 38TH AVE N STE G4
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-347-2557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6449 38TH AVE N STE G4
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-347-2557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN-OWNER
-----------------------------------------------------
Name | DR. JAN STEWART BENDER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 727-347-2557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 55667
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------