MEDICARE: BENJAMIN CHARLES MINOR PT

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	208100000X	Physical Medicine & Rehabilitation Physician	05013667A	IN

General Provider Information

NPI Number	:	1184323149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN CHARLES MINOR PT

Provider Business Mailing Address
First Line	:	1001 PEACOCK RD
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-2836
Country	:	US
Telephone Number	:	765-993-2885
Fax Number	:

Provider Business Practice Location Address
First Line	:	2021 CHESTER BLVD
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-1235
Country	:	US
Telephone Number	:	765-983-3092
Fax Number	:

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

Provider Enumeration Date	:	02/28/2023
Last Update Date	:	02/28/2023

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