Basic Information
| Provider Information | |||||||||
| NPI: | 1629413828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENNY | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6343 E MAIN ST STE 12 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852058955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808356100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6750 E BAYWOOD AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852061749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808356100 | ||||||||
| FaxNumber: | 4804614243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2013 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BP10047477 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0001X | 62485 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
No ID Information.