Provider Demographics
NPI:1285651240
Name:BENEVICH, THERESE (MD)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:BENEVICH
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 1:24 FRANK LLOYD WRIGHT
Mailing Address - Street 2:J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:4940 W CLARK RD STE 100
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-0860
Practice Address - Country:US
Practice Address - Phone:734-971-1188
Practice Address - Fax:734-971-3658
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063592208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N53240042Medicare PIN