Basic Information
| Provider Information | |||||||||
| NPI: | 1437133121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENFIELD | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 BARRET AVE | ||||||||
| Address2: | STE 112 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402041732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023279100 | ||||||||
| FaxNumber: | 8556328329 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 BARRET AVE | ||||||||
| Address2: | STE 112 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022008259 | ||||||||
| FaxNumber: | 5025848379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207R00000X | 01056286A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 38836 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME122430 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2448540000 | 01 | PASSPORT ADVANTAGE | OTHER | 64097728 | 05 | KY | MEDICAID | 000000365262 | 01 | BCBS | OTHER | P00222068 | 01 | RAILROAD MEDICARE | OTHER |