Basic Information
| Provider Information | |||||||||
| NPI: | 1922052208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENZ | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2968 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301569117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707790015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 JOHNSON FERRY RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048518000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 11/12/2008 | ||||||||
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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 | 363AM0700X | 004114 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 004114 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 744705159B | 05 | GA | MEDICAID | 10043450 | 01 | GA | AMERIGROUP | OTHER | 333432 | 01 | GA | WELLCARE | OTHER | 744705159 | 05 | GA | MEDICAID | 744705159A | 05 | GA | MEDICAID |