Basic Information
| Provider Information | |||||||||
| NPI: | 1760454078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENBOW | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388 | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229390388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409325162 | ||||||||
| FaxNumber: | 5409325875 | ||||||||
| Practice Location | |||||||||
| Address1: | 78 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229392332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409324000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 06/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0102037018 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 0102037018 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005880351 | 05 | VA | MEDICAID | 3810015628 | 05 | WV | MEDICAID | 1760454078 | 05 | VA | MEDICAID | 236392 | 01 | VA | BLUE SHIELD | OTHER |