Basic Information
Provider Information
NPI: 1003016916
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NICHOLSON
FirstName: BENJAMIN
MiddleName: P
NamePrefix: DR.
NameSuffix:  
Credential: M.D., M.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2848 NILES RD
Address2:  
City: SAINT JOSEPH
State: MI
PostalCode: 490853352
CountryCode: US
TelephoneNumber: 2694283300
FaxNumber: 2694285005
Practice Location
Address1: 2848 NILES RD
Address2:  
City: SAINT JOSEPH
State: MI
PostalCode: 490853352
CountryCode: US
TelephoneNumber: 2694283300
FaxNumber: 2694285005
Other Information
ProviderEnumerationDate: 07/19/2007
LastUpdateDate: 03/27/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207W00000X4301106941MIN Allopathic & Osteopathic PhysiciansOphthalmology 
207WX0107X4301106941MIY    

No ID Information.


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