Healthcare Provider Details

I. General information

NPI: 1740602077
Provider Name (Legal Business Name): BEN R MAYNE III
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2014
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W WACKERLY ST SUITE 2600
MIDLAND MI
48640-4722
US

IV. Provider business mailing address

555 W WACKERLY ST SUITE 2600
MIDLAND MI
48640-4722
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-8865
  • Fax: 989-492-7839
Mailing address:
  • Phone: 989-839-8865
  • Fax: 989-492-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberBM406830
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006775
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003053
License Number StateMI

VIII. Authorized Official

Name: BEN R MAYNE III
Title or Position: OWNER
Credential: MD
Phone: 989-839-8865