MEDICARE: MR. BRIAN EDWARD BENHAM CRNA

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	367500000X	Certified Registered Nurse Anesthetist	647023	TX

General Provider Information

NPI Number	:	1740270503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN EDWARD BENHAM CRNA

Provider Business Mailing Address
First Line	:	110 QUARRY PT
Second Line	:
City	:	NEW BRAUNFELS
State	:	TX
Zip	:	78132-4418
Country	:	US
Telephone Number	:	830-629-0959
Fax Number	:

Provider Business Practice Location Address
First Line	:	BROOKE ARMY MEDICAL CENTER MCHE-QD/CREDENTIALS
Second Line	:	3851 ROGER BROOKE DRIVE
City	:	FT. SAM HOUSTON
State	:	TX
Zip	:	78234-6200
Country	:	US
Telephone Number	:	210-221-6329
Fax Number	:

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

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	07/08/2007

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