Provider Demographics
NPI:1093896029
Name:LARRY BENNETT MEDICAL L L C
Entity Type:Organization
Organization Name:LARRY BENNETT MEDICAL L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-773-4433
Mailing Address - Street 1:217 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2576
Mailing Address - Country:US
Mailing Address - Phone:989-773-4433
Mailing Address - Fax:989-772-9522
Practice Address - Street 1:217 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2576
Practice Address - Country:US
Practice Address - Phone:989-773-4433
Practice Address - Fax:989-772-9522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093896029Medicaid
MI1103710492OtherBCBSM
MI1093896029Medicaid