Provider Demographics
NPI:1366500092
Name:ROBERTO BENEJAM MD PC
Entity Type:Organization
Organization Name:ROBERTO BENEJAM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:BENEJAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-581-8442
Mailing Address - Street 1:13700 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3489
Mailing Address - Country:US
Mailing Address - Phone:313-581-8442
Mailing Address - Fax:313-581-8486
Practice Address - Street 1:13700 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3489
Practice Address - Country:US
Practice Address - Phone:313-581-8442
Practice Address - Fax:313-581-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2764248Medicaid
MI2764248Medicaid