Provider Demographics
NPI:1588791024
Name:FERN, BENJAMIN (PT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:FERN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 WESTMARK DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2271
Mailing Address - Country:US
Mailing Address - Phone:563-588-3891
Mailing Address - Fax:563-588-3893
Practice Address - Street 1:4005 WESTMARK DR
Practice Address - Street 2:SUITE 320
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2271
Practice Address - Country:US
Practice Address - Phone:563-588-3891
Practice Address - Fax:563-588-3893
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
03661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665463Medicaid
IA0665463Medicaid