Basic Information
Provider Information | |||||||||
NPI: | 1033125372 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENJAMIN | ||||||||
FirstName: | MARSHALL | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 HOSPITAL DR | ||||||||
Address2: | STE 132 | ||||||||
City: | GLEN BURNIE | ||||||||
State: | MD | ||||||||
PostalCode: | 210616902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107874594 | ||||||||
FaxNumber: | 4105538349 | ||||||||
Practice Location | |||||||||
Address1: | 301 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | GLEN BURNIE | ||||||||
State: | MD | ||||||||
PostalCode: | 210615803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105538300 | ||||||||
FaxNumber: | 4105538349 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 11/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | D0050688 | MD | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0000871201 | 05 | DE |   | MEDICAID | 0016 | 01 | MD | CAREFIRST | OTHER | 65473 | 01 | MD | GEISINGER | OTHER | 013756100 | 05 | MD |   | MEDICAID | 112716 | 01 | MD | US HLTHCARE | OTHER | 1727681 | 01 | MD | UNITED HLTHCARE NATIONAL | OTHER | 340305 | 01 | MD | MDIPA | OTHER | 1700756 | 01 | MD | UNITED HLTHCARE | OTHER | 214349 | 01 | MD | KAISER | OTHER | 54350203 | 01 | MD | BLUE SHIELD | OTHER |