Provider Demographics
NPI:1194929265
Name:BENZ, THERESA M (MASTECTOMY FITTER)
Entity type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:M
Last Name:BENZ
Suffix:
Gender:F
Credentials:MASTECTOMY FITTER
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:
Other - Last Name:BENZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1001 BALTIMORE PIKE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064
Mailing Address - Country:US
Mailing Address - Phone:610-604-0950
Mailing Address - Fax:610-604-0970
Practice Address - Street 1:1001 BALTIMORE PIKE
Practice Address - Street 2:SUITE 205
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064
Practice Address - Country:US
Practice Address - Phone:610-604-0950
Practice Address - Fax:610-604-0970
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1435174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232916OtherBCBS
PA4072250001Medicare ID - Type Unspecified