Provider Demographics
NPI:1386975035
Name:DR TERRANCE J BENDA SC
Entity type:Organization
Organization Name:DR TERRANCE J BENDA SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BENDA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-334-5137
Mailing Address - Street 1:1626 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4936
Mailing Address - Country:US
Mailing Address - Phone:262-334-5137
Mailing Address - Fax:262-334-2009
Practice Address - Street 1:1626 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-4936
Practice Address - Country:US
Practice Address - Phone:262-334-5137
Practice Address - Fax:262-334-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI391-25213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43206600Medicaid
WI4426500001Medicare NSC
WI43206600Medicaid
WI84096Medicare PIN