Basic Information
| Provider Information | |||||||||
| NPI: | 1972512655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENSON | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | NILS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19841 N 27TH AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235826420 | ||||||||
| FaxNumber: | 6235826720 | ||||||||
| Practice Location | |||||||||
| Address1: | 19841 N 27TH AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235826420 | ||||||||
| FaxNumber: | 6235826720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 01/04/2008 | ||||||||
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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 | 208800000X | 1521 | AZ | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | AZ0066690 | 01 | AZ | BLUECROSSBLUESHIELDAZ | OTHER | 1Z0539 | 01 | AZ | HEALTHNET | OTHER | 4316747 | 01 | AZ | AETNA | OTHER | 246729 | 05 | AZ | MEDICAID |