MEDICARE: MARK G BENEDICT RN

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	163WC0200X	Critical Care Medicine Registered Nurse	041314705	IL

General Provider Information

NPI Number	:	1154558542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK G BENEDICT RN

Provider Business Mailing Address
First Line	:	519 MAIN ST
Second Line	:
City	:	GREENFIELD
State	:	IL
Zip	:	62044-1321
Country	:	US
Telephone Number	:	217-358-3075
Fax Number	:

Provider Business Practice Location Address
First Line	:	519 MAIN ST
Second Line	:
City	:	GREENFIELD
State	:	IL
Zip	:	62044-1321
Country	:	US
Telephone Number	:	217-358-3075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2009
Last Update Date	:	06/12/2009

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