=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487946372
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIK BENITEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2011
-----------------------------------------------------
Last Update Date | 03/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 972 W MAIN ST CONCENTRA URGENT CARE
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06053-3487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-827-0745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 STATE ST APT 14
-----------------------------------------------------
City | NORTH HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06473-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-336-5436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 53822
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------