Basic Information
| Provider Information | |||||||||
| NPI: | 1982828364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAUCK | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1400 S GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | 9017593196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1458 W POPLAR AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380170630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | 9017595571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 22342 | MS | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0106X | 45172 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 194518001 | 05 | AR | MEDICAID | 100178982 | 05 | MS | MEDICAID | 1529559 | 05 | TN | MEDICAID | 100178983 | 05 | MS | MEDICAID | 01984078 | 05 | MS | MEDICAID | 100178984 | 05 | MS | MEDICAID |