Basic Information
| Provider Information | |||||||||
| NPI: | 1700980281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3225 HOSPITAL DR | ||||||||
| Address2: | UNIT 101A | ||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194755443 | ||||||||
| FaxNumber: | 9074635868 | ||||||||
| Practice Location | |||||||||
| Address1: | 3245 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194755443 | ||||||||
| FaxNumber: | 9074635868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36085 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 6945 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8914544 | 05 | NC | MEDICAID | MD9828 | 05 | AK | MEDICAID |