Healthcare Provider Details

I. General information

NPI: 1902160385
Provider Name (Legal Business Name): BENJAMIN D WILLENBRING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 DIVISION AVE S
GRAND RAPIDS MI
49503-4537
US

IV. Provider business mailing address

1900 44TH ST SE
KENTWOOD MI
49508-5008
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-3800
  • Fax: 616-235-0913
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301106839
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: