Basic Information
Provider Information | |||||||||
NPI: | 1548205891 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENSON | ||||||||
FirstName: | MANFERD | ||||||||
MiddleName: | TREMAIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 925 E SUPERIOR ST | ||||||||
Address2: | SUITE 109 | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558022238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187223700 | ||||||||
FaxNumber: | 2187228705 | ||||||||
Practice Location | |||||||||
Address1: | 925 E SUPERIOR ST | ||||||||
Address2: | SUITE 109 | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558022238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187223700 | ||||||||
FaxNumber: | 2187228705 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2006 | ||||||||
LastUpdateDate: | 10/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 41142 | MN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0016-0009754 | 01 | MN | MEDICA | OTHER | 1598722688 | 01 | MN | UCARE | OTHER |