Basic Information
Provider Information
NPI: 1114982543
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BENEDICT
FirstName: MARY
MiddleName: K
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2374 VILLAGE COMMON DR
Address2: STE 100
City: ERIE
State: PA
PostalCode: 165067201
CountryCode: US
TelephoneNumber: 8144542401
FaxNumber: 8144595992
Practice Location
Address1: 2374 VILLAGE COMMON DR
Address2: STE 100
City: ERIE
State: PA
PostalCode: 165067201
CountryCode: US
TelephoneNumber: 8148350300
FaxNumber: 8148350305
Other Information
ProviderEnumerationDate: 04/19/2006
LastUpdateDate: 01/11/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT006521LPAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
176061801 HIGHMARKOTHER
096664YGB01PAMEDICARE - PAOTHER


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