1093713679 NPI number — LESLIE BENNETT-GRANATA MD

Table of content: LESLIE BENNETT-GRANATA MD (NPI 1093713679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093713679 NPI number — LESLIE BENNETT-GRANATA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT-GRANATA
Provider First Name:
LESLIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1093713679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 E BACON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSDALE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49242-1616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-437-7010
Provider Business Mailing Address Fax Number:
517-437-7627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 HIDDEN MEADOWS DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
HILLSDALE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49242-9812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-437-0010
Provider Business Practice Location Address Fax Number:
517-437-0319
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301075087 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P107546 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080160720 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103257 . This is a "GLHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0120145 . This is a "PHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0803000492 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4210900 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com