Provider Demographics
NPI:1508804154
Name:BRUINSMA, BENJAMIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:J
Last Name:BRUINSMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8186
Mailing Address - Fax:616-840-9637
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5229
Practice Address - Country:US
Practice Address - Phone:616-840-8186
Practice Address - Fax:616-840-9637
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301405949208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2577423Medicaid
MIBB405949OtherSTATE LICENSE
0412849Medicare ID - Type Unspecified
MI2577423Medicaid