Provider Demographics
NPI:1184766776
Name:HEATH, BENJAMIN (PA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:HEATH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 E BIG BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2015
Mailing Address - Country:US
Mailing Address - Phone:248-680-9000
Mailing Address - Fax:248-680-2929
Practice Address - Street 1:1819 E BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2015
Practice Address - Country:US
Practice Address - Phone:248-680-9000
Practice Address - Fax:248-680-2929
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant