Provider Demographics
NPI:1780639849
Name:SELITSKY, BENSON (DO)
Entity Type:Individual
Prefix:
First Name:BENSON
Middle Name:
Last Name:SELITSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1182 STONECREST DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48302-2840
Mailing Address - Country:US
Mailing Address - Phone:248-737-2669
Mailing Address - Fax:
Practice Address - Street 1:5050 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3249
Practice Address - Country:US
Practice Address - Phone:313-581-2600
Practice Address - Fax:313-581-0228
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010058672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI027698OtherMIDWEST HEALTH PLAN
MI120191OtherGREAT LAKES HEALTH PLAN
MI300Q264480OtherBCBSM/BCN
MI57100OtherOMNICARE HEALTH PLAN
MI114445728Medicaid
MI5790032OtherAETNA
MI0Q26448010Medicare ID - Type Unspecified
MIB47847Medicare UPIN