Provider Demographics
NPI:1245111525
Name:POTRYKUS, BENJAMIN ELLIS
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ELLIS
Last Name:POTRYKUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 EMPIRE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-3217
Mailing Address - Country:US
Mailing Address - Phone:401-227-7121
Mailing Address - Fax:
Practice Address - Street 1:119 EMPIRE ST STE 101
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-3217
Practice Address - Country:US
Practice Address - Phone:401-227-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker