Provider Demographics
NPI:1144481821
Name:FLANNERY, BENJAMIN J (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:J
Last Name:FLANNERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-4854
Mailing Address - Country:US
Mailing Address - Phone:507-646-1494
Mailing Address - Fax:
Practice Address - Street 1:2000 NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-4854
Practice Address - Country:US
Practice Address - Phone:507-646-1494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA39346208000000X
MN54106208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1144481821Medicaid