Provider Demographics
NPI:1972771129
Name:BENEDETTO DERMATOLOGY, LLC
Entity type:Organization
Organization Name:BENEDETTO DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:V
Authorized Official - Last Name:BENEDETTO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-546-3666
Mailing Address - Street 1:1200 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5605
Mailing Address - Country:US
Mailing Address - Phone:215-546-3666
Mailing Address - Fax:215-546-6060
Practice Address - Street 1:1200 LOCUST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5605
Practice Address - Country:US
Practice Address - Phone:215-546-3666
Practice Address - Fax:215-546-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207ND0101X207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101750OtherHIGHMARK BLUE SHIELD
PA0274011000OtherINDEPENDENCE BLUE CROSS
PA0274011000OtherINDEPENDENCE BLUE CROSS