MEDICARE: MRS. MARY PATRICIA BENZEL LMP

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	174400000X	Specialist	MA00017628	WA

General Provider Information

NPI Number	:	1740319748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY PATRICIA BENZEL LMP

Provider Business Mailing Address
First Line	:	4534 NW RAE CT
Second Line	:
City	:	CAMAS
State	:	WA
Zip	:	98607-8523
Country	:	US
Telephone Number	:	360-921-0554
Fax Number	:

Provider Business Practice Location Address
First Line	:	337 NE 5TH AVE
Second Line	:
City	:	CAMAS
State	:	WA
Zip	:	98607-2030
Country	:	US
Telephone Number	:	360-921-0554
Fax Number	:

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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