1053305110 NPI number — BENJAMIN O OSOWA M.D.

Table of content: BENJAMIN O OSOWA M.D. (NPI 1053305110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053305110 NPI number — BENJAMIN O OSOWA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OSOWA
Provider First Name:
BENJAMIN
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053305110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18263 E 10 MILE RD
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-5805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-552-8696
Provider Business Mailing Address Fax Number:
586-552-4404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18263 E 10 MILE RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066-5805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-552-8696
Provider Business Practice Location Address Fax Number:
586-552-4404
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301062528 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 609344516 . This is a "DOL/WORKERS COMP GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1053305110 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 159065 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5493662 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: BO062528 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700E031610 . This is a "BCBSM GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700E012740 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00386958 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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