=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619387222
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN WELKER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2014
-----------------------------------------------------
Last Update Date | 05/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEDICAL CENTER BLVD MEDICAL BUILDING II SUITE 324
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19013-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-876-0347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3205 FAULKLAND RD
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | RT004368
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------