=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962588566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENZ UROLOGY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 06/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9096 RIVERSIDE DR
-----------------------------------------------------
City | SEAFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19973-3658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-628-4222
-----------------------------------------------------
Fax | 302-628-4225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9096 RIVERSIDE DR
-----------------------------------------------------
City | SEAFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19973-3658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-628-4222
-----------------------------------------------------
Fax | 302-628-4225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS BARTLEY BENZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 302-628-4222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2088P0231X
-----------------------------------------------------
Taxonomy Name | Pediatric Urology Physician
-----------------------------------------------------
License Number | C1-0006739
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------