Provider Demographics
NPI:1972593101
Name:POMERANTZ, BENJAMIN J (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:POMERANTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:JAY
Other - Last Name:POMERANTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7272
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7272
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011165982085R0202X
MT125412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM01100932Medicare PIN