MEDICARE: JACK NILS BENSON DO

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	208800000X	Urology Physician	1521	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0066690	OTHER	AZ	BLUECROSSBLUESHIELDAZ
2	1Z0539	OTHER	AZ	HEALTHNET
3	4316747	OTHER	AZ	AETNA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972512655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK NILS BENSON DO

Provider Business Mailing Address
First Line	:	19841 N 27TH AVE
Second Line	:	SUITE 201
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4005
Country	:	US
Telephone Number	:	623-582-6420
Fax Number	:	623-582-6720

Provider Business Practice Location Address
First Line	:	19841 N 27TH AVE
Second Line	:	SUITE 201
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4005
Country	:	US
Telephone Number	:	623-582-6420
Fax Number	:	623-582-6720

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	01/04/2008

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Directions to “ JACK NILS BENSON DO” Practice Location

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