Basic Information
| Provider Information | |||||||||
| NPI: | 1023246998 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLY | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 SOUTH STATE STREET | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 EAST MEDICAL CENTER DRIVE | ||||||||
| Address2: | 1ST FLOOR UNIVERSITY HOSPITAL ROOM 1B300 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349369035 | ||||||||
| FaxNumber: | 7349365520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 10/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301094347 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 390200000X | 4301094347 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.