Basic Information
| Provider Information | |||||||||
| NPI: | 1548212897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4543 PLEASANT HILL RD | ||||||||
| Address2: | STE A | ||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347593403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079337900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4543 PLEASANT HILL RD | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347593403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079337900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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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 | 146D00000X | 16431 | PR | N | Emergency Medical Service Providers | Personal Emergency Response Attendant | 208D00000X | ACN326 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 005544500 | 05 | FL | MEDICAID | 24403MO | 01 | PR | TRIPLES | OTHER | ACN326 | 01 | FL | MEDICAL LICENSE NUMBER | OTHER |