Basic Information
| Provider Information | |||||||||
| NPI: | 1063675635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOHNEN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 W BENNETT ST | ||||||||
| Address2: | |||||||||
| City: | SALINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481761105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344299377 | ||||||||
| FaxNumber: | 7344298277 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 W BENNETT ST | ||||||||
| Address2: | |||||||||
| City: | SALINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481761105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344299377 | ||||||||
| FaxNumber: | 7344298277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301110377 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1063675635 | 05 | MI | MEDICAID |