1174740229 NPI number — MR. BENJAMIN A BURROUGHS PA-C

Table of content: MR. BENJAMIN A BURROUGHS PA-C (NPI 1174740229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174740229 NPI number — MR. BENJAMIN A BURROUGHS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURROUGHS
Provider First Name:
BENJAMIN
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1174740229
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2799 W GRAND BLVD
Provider Second Line Business Mailing Address:
PHS PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48202-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-916-2695
Provider Business Mailing Address Fax Number:
313-916-2687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2799 W. GRAND BLVD , K-14
Provider Second Line Business Practice Location Address:
HENRY FORD CARDIAC SURGERY POFESSIONAL BUILDING
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-916-2695
Provider Business Practice Location Address Fax Number:
313-916-2687
Provider Enumeration Date:
04/19/2007

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: 207RC0000X , with the licence number:  5601003662 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 5601003662 , 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: 81471378 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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