Provider Demographics
NPI:1366766560
Name:BENECKE, DOUGLAS NEAL (PA-C)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:NEAL
Last Name:BENECKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3990 E BROAD ST
Mailing Address - Street 2:BLDG 11 SECTION 11
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1152
Mailing Address - Country:US
Mailing Address - Phone:614-336-7300
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1936PAMedicaid
SCSC37788510OtherMEDICARE PIN
SCSC37789068OtherMEDICARE PIN