Provider Demographics
NPI:1093737413
Name:BENNETT, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:555 MIDTOWNE STREET NE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5731
Mailing Address - Country:US
Mailing Address - Phone:616-588-1800
Mailing Address - Fax:616-588-1850
Practice Address - Street 1:555 MIDTOWNE STRET NE
Practice Address - Street 2:SUITE 450
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5732
Practice Address - Country:US
Practice Address - Phone:616-588-1800
Practice Address - Fax:616-588-1850
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-09-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301036844207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4377234Medicaid
MI4377234Medicaid