Provider Demographics
NPI:1053305110
Name:OSOWA, BENJAMIN O (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:O
Last Name:OSOWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18263 E 10 MILE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5805
Mailing Address - Country:US
Mailing Address - Phone:586-552-8696
Mailing Address - Fax:586-552-4404
Practice Address - Street 1:18263 E 10 MILE RD
Practice Address - Street 2:SUITE E
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5805
Practice Address - Country:US
Practice Address - Phone:586-552-8696
Practice Address - Fax:586-552-4404
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301062528207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI609344516OtherDOL/WORKERS COMP GROUP NUMBER
MI1053305110Medicaid
MI159065OtherGREAT LAKES HEALTH PLAN
MI5493662OtherAETNA
MIBO062528OtherBCBSM
MI700E031610OtherBCBSM GROUP NUMBER
MI700E012740OtherBCBS GROUP NUMBER
MIP00386958OtherRAILROAD MEDICARE PTAN
MI609344516OtherDOL/WORKERS COMP GROUP NUMBER
MI700E012740OtherBCBS GROUP NUMBER
MIMI3971084Medicare PIN