Basic Information
Provider Information | |||||||||
NPI: | 1073718169 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AUBERGINE | ||||||||
FirstName: | BENITO | ||||||||
MiddleName: | W. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STULL | ||||||||
OtherFirstName: | BENJAMIN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2401 DEMERS AVE | ||||||||
Address2: |   | ||||||||
City: | GRAND FORKS | ||||||||
State: | ND | ||||||||
PostalCode: | 58201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017801891 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1200 S COLUMBIA RD - ALTRU HOSPITAL | ||||||||
Address2: |   | ||||||||
City: | GRAND FORKS | ||||||||
State: | ND | ||||||||
PostalCode: | 58201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017805000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2007 | ||||||||
LastUpdateDate: | 04/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036121374 | IL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 53450-020 | WI | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 57475 | MN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 11216 | ND | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0361213741 | 05 | IL |   | MEDICAID |