Basic Information
| Provider Information | |||||||||
| NPI: | 1023010907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENRILE | ||||||||
| FirstName: | BENEDICTA | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 555 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222438 | ||||||||
| FaxNumber: | 6147224966 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222438 | ||||||||
| FaxNumber: | 6147224966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | 35034843 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 0105149000 | 05 | WV | MEDICAID | 64789043 | 05 | KY | MEDICAID | 0252524 | 05 | OH | MEDICAID |