=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972760692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENJAMIN JOHN, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2008
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1217 KEARNEY ST SUITE 3
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-3571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-984-5001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1217 KEARNEY ST SUITE 3
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-3571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-984-5001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL RECEPTIONIST
-----------------------------------------------------
Name | MRS. FRANCES MARY SMARCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-984-5001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 4301033555
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------