Provider Demographics
NPI:1205329679
Name:RIDDERING, BENNETT GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:GEORGE
Last Name:RIDDERING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1175 WILSON AVE NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49534-6407
Practice Address - Country:US
Practice Address - Phone:616-685-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351028822207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine