Provider Demographics
NPI:1710240403
Name:SAMUEL, BENSSON VARGHESE (MD,)
Entity Type:Individual
Prefix:DR
First Name:BENSSON
Middle Name:VARGHESE
Last Name:SAMUEL
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 1:801 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:484-526-4000
Mailing Address - Fax:
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-745-8040
Practice Address - Fax:313-966-0070
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108064207R00000X, 2084A2900X
PAMT202650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine