Provider Demographics
NPI:1063404036
Name:BENJAMIN IV, FRED A (CRNA)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:A
Last Name:BENJAMIN IV
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 STATE ROUTE 420
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-5619
Mailing Address - Country:US
Mailing Address - Phone:731-824-1939
Mailing Address - Fax:
Practice Address - Street 1:36 BRENTSHIRE SQ
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2245
Practice Address - Country:US
Practice Address - Phone:731-664-1717
Practice Address - Fax:731-664-7114
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000085124163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3622768Medicaid
TN3622769Medicare ID - Type Unspecified