Basic Information
| Provider Information | |||||||||
| NPI: | 1659334332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAGIELLO | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 LAKES PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300435858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048194478 | ||||||||
| FaxNumber: | 9048194993 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE LANDMARK NORTH 20399 ROUTE 19 | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CRANBERRY TWP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247728000 | ||||||||
| FaxNumber: | 7247728040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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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 | 207RG0300X | MD038951E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0016475970005 | 05 | PA | MEDICAID |