Basic Information
| Provider Information | |||||||||
| NPI: | 1437100500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENAVAGE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 N CEDAR CREST BLVD | ||||||||
| Address2: | SUITE 110B | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181042351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109731410 | ||||||||
| FaxNumber: | 6109731449 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CATASAUQUA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180322646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102640411 | ||||||||
| FaxNumber: | 4844034016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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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 | MD027619E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 134561 | 01 | PA | HIGHMARK PA BLUE SHIELD | OTHER | 0017427920002 | 05 | PA | MEDICAID | 080148024 | 01 | PA | PALMETTO RR | OTHER | 500001220 | 01 | PA | CAPITAL BLUE CROSS | OTHER |