Provider Demographics
NPI:1134132038
Name:BENNETT, LARRY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:MICHAEL
Last Name:BENNETT
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 1:217 WEST BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-773-4433
Mailing Address - Fax:989-772-9522
Practice Address - Street 1:217 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-773-4433
Practice Address - Fax:989-772-9522
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILB050345207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1103710492OtherBCBS
MI1134132038Medicaid
MI110097379OtherMEDICARE RR
MI1103710492OtherBCBS
MI1134132038Medicaid