Basic Information
| Provider Information | |||||||||
| NPI: | 1265400782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PISCIOTTA | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 939 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604177000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 939 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604177000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 07/19/2007 | ||||||||
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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 | 2085R0202X | MD00020748 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8553505 | 05 | WA | MEDICAID | 9160PI | 01 | REGENCE BLUE SHIELD RIDER | OTHER | P00177500 | 01 | RAILROAD MEDICARE | OTHER |