Provider Demographics
NPI:1184116436
Name:BENNER, CHANCE (DO)
Entity type:Individual
Prefix:DR
First Name:CHANCE
Middle Name:
Last Name:BENNER
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 1:2104 NORTHVIEW CT NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1269
Mailing Address - Country:US
Mailing Address - Phone:513-262-8794
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGAN ST NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2537
Practice Address - Country:US
Practice Address - Phone:616-459-7258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAHS000102L208600000X, 390200000X
MI5101028055208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program