Provider Demographics
NPI:1801338769
Name:RIEBESEL, BENJAMIN
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:RIEBESEL
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 1:12063 LOWER HUNTINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IN
Mailing Address - Zip Code:46783-9667
Mailing Address - Country:US
Mailing Address - Phone:251-599-6756
Mailing Address - Fax:
Practice Address - Street 1:5734 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7141
Practice Address - Country:US
Practice Address - Phone:260-435-7973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28232032A367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300019421Medicaid
IN412840169OtherMEDICARE
KY7100910520Medicaid