Basic Information
| Provider Information | |||||||||
| NPI: | 1255369104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUSCHA | ||||||||
| FirstName: | BENNIE | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MUSCHA | ||||||||
| OtherFirstName: | BEN | ||||||||
| OtherMiddleName: | W | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1917 SOUTH CRISMON ROAD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806107100 | ||||||||
| FaxNumber: | 4806107115 | ||||||||
| Practice Location | |||||||||
| Address1: | 1917 SOUTH CRISMON ROAD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806107100 | ||||||||
| FaxNumber: | 4806107115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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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 | 207Q00000X | 6633 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 42575 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11681 | 01 | ND | BCBS | OTHER | 17619 | 05 | ND | MEDICAID |