Healthcare Provider Details

I. General information

NPI: 1558949099
Provider Name (Legal Business Name): BENJAMIN MICHON ATC, LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 COMMONWEALTH AVE
AUBURNDALE MA
02466-2709
US

IV. Provider business mailing address

85 WARREN AVE APT 1
MARLBOROUGH MA
01752-3989
US

V. Phone/Fax

Practice location:
  • Phone: 617-243-2168
  • Fax:
Mailing address:
  • Phone: 413-346-8717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number3367
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: