1316994213 NPI number — ANTHONY A BENNETT M D P C

Table of content: (NPI 1316994213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316994213 NPI number — ANTHONY A BENNETT M D P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTHONY A BENNETT M D P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADVANCED VIRTUAL RADIOLOGY PLLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316994213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
441 FRANKLIN WRIGHT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE ORION
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48362-1585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-894-8019
Provider Business Mailing Address Fax Number:
248-799-0473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29777 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-7625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-894-8019
Provider Business Practice Location Address Fax Number:
248-799-0473
Provider Enumeration Date:
05/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
RADIOLOGIST
Authorized Official Telephone Number:
248-894-8019

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X , with the licence number:  AB063302 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: AB063302 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085U0001X , with the licence number: AB063302 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300F392040 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".