Active NPI
Jeremy Benacka
- Physical Therapist
- Maple Grove, MN
National Provider Identifier
1174001010
On this page
OIG exclusion record
The HHS Office of Inspector General’s List of Excluded Individuals/Entities (LEIE) contains a record with this NPI:
- Section 1128a(1) exclusion effective Sep 20, 2022.
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 5489
- Practice address
- 16720 73Rd PL N
Maple Grove, MN 55311-2130 - Phone
- (612) 685-2919
- NPI assigned
- Aug 2, 2018
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 5489 | MN | Primary |
Addresses
Primary practice location
16720 73Rd PL N
Maple Grove, MN 55311-2130
Mailing address
16720 73Rd PL N
Maple Grove, MN 55311-2130
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- HHS exclusion list flag
- Flagged The directory lists this NPI on an HHS exclusion list.
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5489 | MN | MD | Audiologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1533168000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1533168000000",
"number": "1174001010",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "16720 73RD PL N",
"city": "MAPLE GROVE",
"state": "MN",
"postal_code": "553112130"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "16720 73RD PL N",
"city": "MAPLE GROVE",
"state": "MN",
"postal_code": "553112130",
"telephone_number": "612-685-2919"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BENACKA",
"first_name": "JEREMY",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2018-08-02",
"last_updated": "2018-08-02",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "MN",
"license": "5489",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Maple Grove, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 2, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; OIG LEIE.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.