Basic Information
| Provider Information | |||||||||
| NPI: | 1528233889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVID L BENISCH, MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 MAIN ST | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117436922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314237000 | ||||||||
| FaxNumber: | 6314239276 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 MAIN ST | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117436922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314237000 | ||||||||
| FaxNumber: | 6314239276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | BENISCH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | LANCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6314237000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 00425470 | 05 | NY | MEDICAID |