Basic Information
| Provider Information | |||||||||
| NPI: | 1356697577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | COREY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | C-AA, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1225 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325412909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506507606 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1225 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325412909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506507606 | ||||||||
| FaxNumber: | 8503371698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2012 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT27491 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 367H00000X | AA472 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | Y0CP4 | 01 | FL | BCBS | OTHER | P01240342 | 01 | RAILROAD MEDICARE | OTHER | 101045800 | 05 | FL | MEDICAID |