Healthcare Provider Details

I. General information

NPI: 1134863772
Provider Name (Legal Business Name): BENEDICT JOHN FREDERICK IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19000 ST JOES PKWY STE 310
LIVONIA MI
48152-1477
US

IV. Provider business mailing address

222 E FRANK ST
KALAMAZOO MI
49007-3515
US

V. Phone/Fax

Practice location:
  • Phone: 734-743-4540
  • Fax:
Mailing address:
  • Phone: 410-615-8558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: