Provider Demographics
NPI:1093904468
Name:WOOD, BENJAMIN T
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:T
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 HOLLYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9159
Mailing Address - Country:US
Mailing Address - Phone:269-429-8010
Mailing Address - Fax:269-429-0986
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9159
Practice Address - Country:US
Practice Address - Phone:269-429-8010
Practice Address - Fax:269-429-0986
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017283207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093904468Medicaid
MI1093904468Medicaid