Basic Information
| Provider Information | |||||||||
| NPI: | 1710922331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENEVICH | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7000 NORTH MOPAC | ||||||||
| Address2: | SUITE #420 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124820045 | ||||||||
| FaxNumber: | 5124769892 | ||||||||
| Practice Location | |||||||||
| Address1: | 7000 NORTH MOPAC | ||||||||
| Address2: | SUITE #420 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124820045 | ||||||||
| FaxNumber: | 5124769892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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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 | M1020 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 176649501 | 05 | TX | MEDICAID | 1766495-02 | 05 | TX | MEDICAID |