Provider Demographics
NPI:1427102466
Name:BANSE, LENISE ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:LENISE
Middle Name:ANNE
Last Name:BANSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-7190
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:42452 HAYES RD
Practice Address - Street 2:SUITE 3
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6771
Practice Address - Country:US
Practice Address - Phone:586-263-3130
Practice Address - Fax:586-263-5183
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047653207N00000X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE21671Medicare UPIN
MIE21671Medicare UPIN
MI0500688Medicare ID - Type UnspecifiedMEDICARE
MI0500688OtherBCBS OF MICHIGAN
MIMO22874OtherTRICARE
MIDR500262OtherMCARE
MI155665OtherGREAT LAKES HEALTH PLAN
MIP50460001Medicare PIN
MI0500688001OtherMEDICARE PLUS BLUE
MI80862BOtherHEALTH ALLIANCE PLAN
MI101151OtherCARE CHOICES
MI2806900Medicaid
MI101151OtherPREFERRED CHOICES
MI4037111OtherAETNA
MI900013288OtherPRIORITY HEALTH