1780639849 NPI number — BENSON SELITSKY DO

Table of content: BENSON SELITSKY DO (NPI 1780639849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780639849 NPI number — BENSON SELITSKY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELITSKY
Provider First Name:
BENSON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1780639849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1182 STONECREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302-2840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-737-2669
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 SCHAEFER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48126-3249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-581-2600
Provider Business Practice Location Address Fax Number:
313-581-0228
Provider Enumeration Date:
05/24/2006

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: 2085R0202X , with the licence number:  5101005867 , 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: 027698 . This is a "MIDWEST HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 120191 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 300Q264480 . This is a "BCBSM/BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 57100 . This is a "OMNICARE HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 114445728 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5790032 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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