Basic Information
| Provider Information | |||||||||
| NPI: | 1124279492 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BENJAMIN A WHITE, DO., LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 513 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | ROSSFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434601246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196665202 | ||||||||
| FaxNumber: | 4196667081 | ||||||||
| Practice Location | |||||||||
| Address1: | 513 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | ROSSFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434601246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196665202 | ||||||||
| FaxNumber: | 4196667081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2008 | ||||||||
| LastUpdateDate: | 10/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4196665202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | 4196665202 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 34.007296 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 2293905 | 05 | OH | MEDICAID |