Provider Demographics
NPI:1871577635
Name:BENEDETTO, MICHAEL ANTHONY (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:BENEDETTO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 PROFESSIONAL VILLAGE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907
Mailing Address - Country:US
Mailing Address - Phone:843-986-9670
Mailing Address - Fax:843-986-9369
Practice Address - Street 1:18 PROFESSIONAL VILLAGE CIRCLE
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907
Practice Address - Country:US
Practice Address - Phone:843-986-9670
Practice Address - Fax:843-986-9369
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q25457Medicare UPIN