Basic Information
| Provider Information | |||||||||
| NPI: | 1649636705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HURSTON | ||||||||
| FirstName: | BENJMAIN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 TECHNACENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361176028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346255795 | ||||||||
| FaxNumber: | 3343964905 | ||||||||
| Practice Location | |||||||||
| Address1: | 7061 HALCYON SUMMIT DR | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361176927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343962110 | ||||||||
| FaxNumber: | 3343962115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2016 | ||||||||
| LastUpdateDate: | 03/15/2016 | ||||||||
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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 | 225100000X | PTH7899 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 13774482 | 01 | AK | CAQH | OTHER | 511-73438 | 01 | AL | BCBS OF AL | OTHER | 511-73432 | 01 | AL | BCBS OF AL | OTHER | 511-73434 | 01 | AL | BCBS OF AL | OTHER | 511-73440 | 01 | AL | BCBS OF AL | OTHER |