Provider Demographics
NPI:1750818308
Name:HUBER, BENJAMIN MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:HUBER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19251 MACK AVE
Mailing Address - Street 2:STE 333
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2898
Mailing Address - Country:US
Mailing Address - Phone:313-343-7784
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD STE 50
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-7784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315215584207R00000X
MI5101025476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine