Basic Information
| Provider Information | |||||||||
| NPI: | 1356604144 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENSON | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432128080 | ||||||||
| FaxNumber: | 8432128081 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294837315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432128080 | ||||||||
| FaxNumber: | 8432128081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2012 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | LL34719 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34719 | 01 | SC | MEDICAL LICENSE | OTHER |