Provider Demographics
NPI:1114705233
Name:EBERT, BENJAMIN KARL (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KARL
Last Name:EBERT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 RIVA RD STE 114
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7428
Mailing Address - Country:US
Mailing Address - Phone:410-573-2530
Mailing Address - Fax:410-573-2536
Practice Address - Street 1:2629 RIVA RD STE 114
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7428
Practice Address - Country:US
Practice Address - Phone:410-573-2530
Practice Address - Fax:410-573-2536
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant