Provider Demographics
NPI:1174740229
Name:BURROUGHS, BENJAMIN A (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:A
Last Name:BURROUGHS
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-2695
Mailing Address - Fax:313-916-2687
Practice Address - Street 1:2799 W. GRAND BLVD , K-14
Practice Address - Street 2:HENRY FORD CARDIAC SURGERY POFESSIONAL BUILDING
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2695
Practice Address - Fax:313-916-2687
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2023-10-25
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Provider Licenses
StateLicense IDTaxonomies
NM5601003662207RC0000X
MI5601003662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81471378Medicaid
81471378Medicare PIN
P52475Medicare UPIN