Basic Information
Provider Information | |||||||||
NPI: | 1932165628 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENJAMIN | ||||||||
FirstName: | ANTHONY | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14890 | ||||||||
Address2: |   | ||||||||
City: | ALBANY | ||||||||
State: | NY | ||||||||
PostalCode: | 122124890 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5185255634 | ||||||||
FaxNumber: | 5186494094 | ||||||||
Practice Location | |||||||||
Address1: | 2231 BURDETT AVE STE 230 | ||||||||
Address2: |   | ||||||||
City: | TROY | ||||||||
State: | NY | ||||||||
PostalCode: | 12180 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182721333 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2006 | ||||||||
LastUpdateDate: | 05/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 229456 | NY | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 1099291 | 01 |   | GHI PPO# | OTHER | 71021424811 | 01 |   | MVP VENDOR # | OTHER | 02491927 | 05 | NY |   | MEDICAID | 100783615671 | 01 |   | CDPHP GROUP # | OTHER | P00063770 | 01 |   | RR MEDICARE | OTHER | 000000076448 | 01 |   | GHI HMO # | OTHER | AB035R241 | 01 |   | DOWN MEDICARE | OTHER |