Provider Demographics
NPI:1740602077
Name:BEN R MAYNE III
Entity Type:Organization
Organization Name:BEN R MAYNE III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAYNE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:989-839-8865
Mailing Address - Street 1:555 W WACKERLY ST
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4722
Mailing Address - Country:US
Mailing Address - Phone:989-839-8865
Mailing Address - Fax:989-492-7839
Practice Address - Street 1:555 W WACKERLY ST
Practice Address - Street 2:SUITE 2600
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4722
Practice Address - Country:US
Practice Address - Phone:989-839-8865
Practice Address - Fax:989-492-7839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBM406830207X00000X
MI5601006775363A00000X
MI5601003053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty