Healthcare Provider Details

I. General information

NPI: 1275769739
Provider Name (Legal Business Name): BENJAMIN MICHAEL BUSMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

UNIVERSITY OF CONNECTICUT SCHOOL OF MEDICINE RESIDENCY ADMINISTRATION AG093
FARMINGTON CT
06067
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3139
  • Fax: 616-391-3044
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number050317
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: