Basic Information
| Provider Information | |||||||||
| NPI: | 1003959412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENTON | ||||||||
| FirstName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E MAIN ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975016041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895526 | ||||||||
| FaxNumber: | 5417895203 | ||||||||
| Practice Location | |||||||||
| Address1: | 781 BLACK OAK DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975049502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894236 | ||||||||
| FaxNumber: | 5417895965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD10154 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 287513 | 05 | OR | MEDICAID |