Provider Demographics
NPI:1518248418
Name:BENJAMIN OUTREACH MEDICAL NETWORK CORPORATION
Entity type:Organization
Organization Name:BENJAMIN OUTREACH MEDICAL NETWORK CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAUNRANCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-312-2529
Mailing Address - Street 1:2843 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-5649
Mailing Address - Country:US
Mailing Address - Phone:954-251-0267
Mailing Address - Fax:954-252-5327
Practice Address - Street 1:3939 HOLLYWOOD BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6749
Practice Address - Country:US
Practice Address - Phone:954-251-0267
Practice Address - Fax:754-212-0473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
FLME95524208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279510800Medicaid