Provider Demographics
NPI:1194967166
Name:BENCY MATHAI MD PLLC
Entity type:Organization
Organization Name:BENCY MATHAI MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BENCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-960-3966
Mailing Address - Street 1:1310 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3077
Mailing Address - Country:US
Mailing Address - Phone:517-960-3966
Mailing Address - Fax:517-787-9183
Practice Address - Street 1:1310 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3077
Practice Address - Country:US
Practice Address - Phone:517-960-3966
Practice Address - Fax:517-787-9183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071335261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherEIN