Basic Information
| Provider Information | |||||||||
| NPI: | 1528068624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIRST COAST GASTROENTEROLOGY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BEN C PINEAU MD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 WHETSTONE PL | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048299557 | ||||||||
| FaxNumber: | 9048299125 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 WHETSTONE PL | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048299557 | ||||||||
| FaxNumber: | 9048299125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 10/09/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PINEAU | ||||||||
| AuthorizedOfficialFirstName: | BENOIT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9048299557 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME90376 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | P00147263 | 01 | MEDICARE RR | OTHER | DC0902 | 01 | MEDICARE RR - GROUP # | OTHER | 44069 | 01 | FL | BCBS | OTHER | 269931100 | 05 | FL | MEDICAID |