Provider Demographics
NPI:1063675635
Name:KOHNEN, BENJAMIN L (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
Last Name:KOHNEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-1105
Mailing Address - Country:US
Mailing Address - Phone:734-429-9377
Mailing Address - Fax:734-429-8277
Practice Address - Street 1:208 W BENNETT ST
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1105
Practice Address - Country:US
Practice Address - Phone:734-429-9377
Practice Address - Fax:734-429-8277
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301110377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063675635Medicaid
MI1063675635Medicaid