Provider Demographics
NPI:1831147768
Name:GO, BENEDICT (MD)
Entity type:Individual
Prefix:
First Name:BENEDICT
Middle Name:
Last Name:GO
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:PO BOX 422
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-0422
Mailing Address - Country:US
Mailing Address - Phone:734-692-6676
Mailing Address - Fax:734-692-6618
Practice Address - Street 1:14720 KING RD
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7945
Practice Address - Country:US
Practice Address - Phone:734-692-6676
Practice Address - Fax:734-692-6618
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057837207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4534238Medicaid
MI4534238Medicaid
MION93930Medicare PIN
MI0N93930001Medicare ID - Type Unspecified