Basic Information
| Provider Information | |||||||||
| NPI: | 1811925001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENINK | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015458336 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015458699 | ||||||||
| FaxNumber: | 9015458996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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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 | 207PE0004X | 036077518 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 52241 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 834340 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 553180035 | 01 | IL | MEDICARE INDIVIDUAL PTAN | OTHER | 834340023 | 01 | IL | MEDICARE INDIVIDUAL PTAN | OTHER | 553180 | 01 | IL | MEDICARE GROUP PTAN | OTHER | 36077518 | 05 | IL | MEDICAID |