Provider Demographics
NPI:1861874190
Name:BENNETT, AMANDA R (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:R
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:866-611-1512
Mailing Address - Fax:231-728-4789
Practice Address - Street 1:1150 E SHERMAN BLVD STE 1175
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1885
Practice Address - Country:US
Practice Address - Phone:231-672-6740
Practice Address - Fax:231-672-6749
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861874190Medicaid