Basic Information
| Provider Information | |||||||||
| NPI: | 1477752582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJP - PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443199 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 6TH ST S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278236297 | ||||||||
| FaxNumber: | 7278239502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 02/18/2009 | ||||||||
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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 | 367500000X | ARNP9195596 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 578456425A | 05 | GA | MEDICAID | P00661592 | 01 | RAILROAD MEDICARE ASSOCIATED TO GROUP CF4811 | OTHER | G4295 | 01 | FL | BLUE CROSS | OTHER | 3084876-00 | 05 | FL | MEDICAID |