Basic Information
| Provider Information | |||||||||
| NPI: | 1023350113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAN | ||||||||
| FirstName: | BENSEN | ||||||||
| MiddleName: | BENJAMIN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416457 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022416457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 MADISON AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079607337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739717830 | ||||||||
| FaxNumber: | 9735381065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2013 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 25MA10638900 | NJ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | A154107 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.