Basic Information
| Provider Information | |||||||||
| NPI: | 1174554364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1964 11 MILE RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BERKLEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480723046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485449300 | ||||||||
| FaxNumber: | 2485441148 | ||||||||
| Practice Location | |||||||||
| Address1: | 1964 11 MILE RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BERKLEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480723046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485449300 | ||||||||
| FaxNumber: | 2485441148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101007480 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11271806 | 01 | CAQH PROVIDER ID # | OTHER | G07355 | 01 | MI | BCN GROUP # | OTHER | PB007480 | 01 | MI | STATE LICENSE # | OTHER |