Basic Information
| Provider Information | |||||||||
| NPI: | 1922489962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | ATTN PATIENT ACCOUNTING | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432346946 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2361 CYPRESS CIRCLE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433473900 | ||||||||
| FaxNumber: | 8433473930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2015 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101269486 | VA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MMD.31487 LL | SC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 38417 | SC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 384177 | 05 | SC | MEDICAID |