Provider Demographics
NPI:1427234277
Name:MIRIOVSKY, BENJAMIN JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JOHN
Last Name:MIRIOVSKY
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 18428
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-8428
Mailing Address - Country:US
Mailing Address - Phone:256-705-4224
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR SW STE 400
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3495
Practice Address - Country:US
Practice Address - Phone:256-705-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-00444207RH0003X
NE24979207R00000X
ORMD160868207RH0003X
AL42932207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL512-65053OtherBCBS AL
ORP01224287OtherMEDICARE RAILROAD
NC1427234277Medicaid
AL512-65052OtherBCBS AL
AL275147Medicaid
OR500661059Medicaid