Provider Demographics
NPI:1821193491
Name:BENSEN, MICHELLE A (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:BENSEN
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 1:34700 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4500
Mailing Address - Country:US
Mailing Address - Phone:262-646-4411
Mailing Address - Fax:262-646-1049
Practice Address - Street 1:34700 VALLEY RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4500
Practice Address - Country:US
Practice Address - Phone:262-646-4411
Practice Address - Fax:262-646-1049
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38279207R00000X, 208VP0014X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIAPPRMedicaid
WI32484300Medicaid
WI32484300Medicaid
WI0181-44100Medicare PIN
G76632Medicare UPIN