Provider Demographics
NPI:1750415238
Name:SCHIPPER, BENJAMIN RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RUSSELL
Last Name:SCHIPPER
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 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:616-486-0130
Practice Address - Street 1:3185 MACATAWA DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3163
Practice Address - Country:US
Practice Address - Phone:616-391-4500
Practice Address - Fax:616-486-0130
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081988208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4984133Medicaid
MIN10270012Medicare PIN