Provider Demographics
NPI:1750362034
Name:SONG, BENJAMIN J (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:J
Last Name:SONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 JACKSON RD STE 260
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-1889
Mailing Address - Country:US
Mailing Address - Phone:734-434-3007
Mailing Address - Fax:734-434-6317
Practice Address - Street 1:2000 N HURON RIVER DR STE 200
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-434-3007
Practice Address - Fax:734-434-6317
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071851207R00000X, 208000000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104625172Medicaid
MI104630557Medicaid
MI0H161036351Medicare ID - Type UnspecifiedU OF M
H92499Medicare UPIN
MI104630557Medicaid