Provider Demographics
NPI:1275716995
Name:MICHELE L BENNETT MD PC
Entity Type:Organization
Organization Name:MICHELE L BENNETT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-673-6100
Mailing Address - Street 1:248 W WORKS ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4213
Mailing Address - Country:US
Mailing Address - Phone:307-673-6100
Mailing Address - Fax:307-673-1975
Practice Address - Street 1:248 W WORKS ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4213
Practice Address - Country:US
Practice Address - Phone:307-673-6100
Practice Address - Fax:307-673-1975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY05809001OtherBLUE CROSS/BLUE SHIELD
WY05809001OtherBLUE CROSS/BLUE SHIELD
WY20375Medicare PIN