Provider Demographics
NPI:1528057163
Name:BENACK, ANDREA (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BENACK
Suffix:
Gender:F
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:P.O BOX 8277783
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19185-7783
Mailing Address - Country:US
Mailing Address - Phone:215-707-3326
Mailing Address - Fax:215-707-8028
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:3RD FL OUT PATIENT BLDG
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3326
Practice Address - Fax:215-707-8028
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027995E207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B37040Medicare UPIN
117269Medicare ID - Type Unspecified