Basic Information
| Provider Information | |||||||||
| NPI: | 1215955448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENEDICT | ||||||||
| FirstName: | KARL | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 CHESTNUT ST | ||||||||
| Address2: | 14TH FLOOR, CENTRAL ENROLLMENT | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191064404 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2603 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191484310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155518660 | ||||||||
| FaxNumber: | 2155519247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
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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 | 207R00000X | MD-061493-L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7568908 | 05 | NJ | MEDICAID | 001640685 | 05 | PA | MEDICAID |