Basic Information
Provider Information | |||||||||
NPI: | 1760764153 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MASON | ||||||||
FirstName: | BENJAMIN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6451 N FEDERAL HWY STE 800 | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333081409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8005865022 | ||||||||
FaxNumber: | 8159337090 | ||||||||
Practice Location | |||||||||
Address1: | 405 W JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | CARBONDALE | ||||||||
State: | IL | ||||||||
PostalCode: | 629011462 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185490721 | ||||||||
FaxNumber: | 6184570469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2011 | ||||||||
LastUpdateDate: | 02/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2014021727 | MO | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 25MA10391100 | NJ | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 52272 | CT | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 61640 | MN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 72056 | GA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | ME120257 | FL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD60830186 | WA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 266988 | NY | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 04-40604 | KS | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 18640 | NH | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | A135734 | CA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD0000058008 | TN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD22061 | ME | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD458235 | PA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 036142404 | IL | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2124574 | 05 | WA |   | MEDICAID |