Basic Information
| Provider Information | |||||||||
| NPI: | 1649666223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LANCASTER AVE STE B11 | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190963450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4844762658 | ||||||||
| FaxNumber: | 4844763577 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E LANCASTER AVE STE B11 | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4844762658 | ||||||||
| FaxNumber: | 4844763577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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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 | MD461715 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD461715 | PA | N | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.