Basic Information
| Provider Information | |||||||||
| NPI: | 1386626398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENDELL | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 OHIO BLVD | ||||||||
| Address2: | SUITE 127 | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478032239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122348261 | ||||||||
| FaxNumber: | 8122348262 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 1 BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | LINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474419482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128472281 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01037092A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100124880 | 05 | IN | MEDICAID |