Provider Demographics
NPI:1245313907
Name:BENEDICT, BRYAN S (MSPT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:S
Last Name:BENEDICT
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 STURBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-9653
Mailing Address - Country:US
Mailing Address - Phone:269-343-1372
Mailing Address - Fax:
Practice Address - Street 1:2340 E CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4465
Practice Address - Country:US
Practice Address - Phone:269-327-7075
Practice Address - Fax:269-327-7196
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist