Basic Information
Provider Information | |||||||||
NPI: | 1003914888 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BENJAMIN A. WENDELL, MD LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2901 OHIO BLVD | ||||||||
Address2: | SUITE 127 | ||||||||
City: | TERRE HAUTE | ||||||||
State: | IN | ||||||||
PostalCode: | 478032239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122348261 | ||||||||
FaxNumber: | 8122348262 | ||||||||
Practice Location | |||||||||
Address1: | RR 1 BOX 1000 | ||||||||
Address2: |   | ||||||||
City: | LINTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474419482 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128472281 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 06/14/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WENDELL | ||||||||
AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
AuthorizedOfficialTelephone: | 8122323664 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01037092A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 100124880 | 05 | IN |   | MEDICAID |