=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881074482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN T GILBERT PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2015
-----------------------------------------------------
Last Update Date | 06/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 ELM ST
-----------------------------------------------------
City | WEST HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06516-4233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-223-3511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 STRATFORD AVE APARTMENT 511
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06615-6344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-223-3511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 003341
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------