Provider Demographics
NPI:1023041951
Name:MAYNE, BEN R III (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:R
Last Name:MAYNE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:555 W WACKERLY ST
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4722
Mailing Address - Country:US
Mailing Address - Phone:989-839-8865
Mailing Address - Fax:989-631-7337
Practice Address - Street 1:555 W WACKERLY ST
Practice Address - Street 2:SUITE 2600
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-839-8865
Practice Address - Fax:989-631-7337
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2018-09-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301406830207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2738032Medicaid
MIE83429Medicare UPIN
MI0P43710Medicare PIN