Provider Demographics
NPI:1093713679
Name:BENNETT-GRANATA, LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BENNETT-GRANATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 E BACON ST
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-1616
Mailing Address - Country:US
Mailing Address - Phone:517-437-7010
Mailing Address - Fax:517-437-7627
Practice Address - Street 1:451 HIDDEN MEADOWS DR
Practice Address - Street 2:SUITE 120
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9812
Practice Address - Country:US
Practice Address - Phone:517-437-0010
Practice Address - Fax:517-437-0319
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP107546OtherBCN
MI080160720OtherMEDICARE RAILROAD
MI103257OtherGLHP
MI0120145OtherPHP
MI0803000492OtherBCBS
MI4210900Medicaid
MI080160720OtherMEDICARE RAILROAD
MI0803000492OtherBCBS