Basic Information
| Provider Information | |||||||||
| NPI: | 1023545027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | EDDIE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1152 TULSA DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432295513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6199978952 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1791 ALUM CREEK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144458131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2017 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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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 | 164W00000X | 162941 | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 0129422 | 05 | OH | MEDICAID |