MEDICARE: MR. BENJAMIN M GUENTHER C.O.,LPO

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	222Z00000X	Orthotist	OI60339265	WA
2	224P00000X	Prosthetist	PS60452668	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OI60339265	OTHER	WA	STATE LICENSE
2	PS60452668	OTHER	WA	PROSTHETIC LICENSE

General Provider Information

NPI Number	:	1306271838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENJAMIN M GUENTHER C.O.,LPO

Provider Business Mailing Address
First Line	:	1110 MEDICAL DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2109
Country	:	US
Telephone Number	:	903-592-5900
Fax Number	:	903-592-6683

Provider Business Practice Location Address
First Line	:	1110 MEDICAL DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2109
Country	:	US
Telephone Number	:	903-592-5900
Fax Number	:	903-592-6683

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

Provider Enumeration Date	:	09/03/2013
Last Update Date	:	04/02/2014

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Directions to “ MR. BENJAMIN M GUENTHER C.O.,LPO” Practice Location

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