MEDICARE: BENEZE MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	14102	AZ

General Provider Information

NPI Number	:	1083659361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENEZE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	3003 HIGHWAY 95
Second Line	:	SUITE G73
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7860
Country	:	US
Telephone Number	:	928-758-7700
Fax Number	:	928-758-5700

Provider Business Practice Location Address
First Line	:	3003 HIGHWAY 95
Second Line	:	SUITE G73
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7860
Country	:	US
Telephone Number	:	928-758-7700
Fax Number	:	928-758-5700

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. LARRY JOSEPH KEATING
Credential	:	P.A.C.
Telephone Number	:	928-758-7700

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	11/17/2010

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Directions to “BENEZE MEDICAL GROUP ” Practice Location

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