Provider Demographics
NPI:1013234707
Name:BRADLEY BENGTSON, M.D. PC
Entity Type:Organization
Organization Name:BRADLEY BENGTSON, M.D. PC
Other - Org Name:BENGTSON CENTER FOR AESTHETICS AND PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENGTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:616-588-8880
Mailing Address - Street 1:555 MIDTOWNE ST NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5729
Mailing Address - Country:US
Mailing Address - Phone:616-588-8880
Mailing Address - Fax:616-588-8881
Practice Address - Street 1:555 MIDTOWNE ST NE
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5729
Practice Address - Country:US
Practice Address - Phone:616-588-8880
Practice Address - Fax:616-588-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407033208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty