Provider Demographics
NPI:1023246998
Name:BLY, BENJAMIN MARTIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MARTIN
Last Name:BLY
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 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DRIVE
Practice Address - Street 2:1ST FLOOR UNIVERSITY HOSPITAL ROOM 1B300
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5036
Practice Address - Country:US
Practice Address - Phone:734-936-9035
Practice Address - Fax:734-936-5520
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010943472084N0400X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program