Provider Demographics
NPI:1215303979
Name:ELLENBERGER, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ELLENBERGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 OLIVE CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-8586
Mailing Address - Country:US
Mailing Address - Phone:919-535-8758
Mailing Address - Fax:
Practice Address - Street 1:103 PARKWAY OFFICE CT
Practice Address - Street 2:102
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7428
Practice Address - Country:US
Practice Address - Phone:919-615-3527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209652225100000X
NCP17060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09457Medicare PIN