Basic Information
| Provider Information | |||||||||
| NPI: | 1174577613 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BENSON FAMILY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41555 COOK ST | ||||||||
| Address2: | STE 130 | ||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603402682 | ||||||||
| FaxNumber: | 7607739695 | ||||||||
| Practice Location | |||||||||
| Address1: | 41555 COOK ST | ||||||||
| Address2: | STE 130 | ||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603402682 | ||||||||
| FaxNumber: | 7607739695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BENSON | ||||||||
| AuthorizedOfficialFirstName: | AURORA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7603402682 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A5361 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 20A4564 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0069290 | 05 | CA | MEDICAID | 00AX45640 | 05 | CA | MEDICAID | 00AX53610 | 05 | CA | MEDICAID |