Provider Demographics
NPI:1316994213
Name:ANTHONY A BENNETT M D P C
Entity type:Organization
Organization Name:ANTHONY A BENNETT M D P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-894-8019
Mailing Address - Street 1:441 FRANKLIN WRIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-1585
Mailing Address - Country:US
Mailing Address - Phone:248-894-8019
Mailing Address - Fax:248-799-0473
Practice Address - Street 1:29777 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7625
Practice Address - Country:US
Practice Address - Phone:248-894-8019
Practice Address - Fax:248-799-0473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAB0633022085B0100X, 2085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300F392040OtherBCBS
MIMI3594Medicare PIN