MEDICARE: ELISSA P BENEDEK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	4301024248	MI
2	2084P0800X	Psychiatry Physician	EB024248	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2618102841	OTHER	MI	BCBS PIN
2	BM810164	OTHER	MI	MCARE

General Provider Information

NPI Number	:	1679615132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISSA P BENEDEK M.D.

Provider Business Mailing Address
First Line	:	2311 E STADIUM BLVD
Second Line	:	SUITE 111
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-4833
Country	:	US
Telephone Number	:	734-665-0074
Fax Number	:	734-665-9383

Provider Business Practice Location Address
First Line	:	2311 E STADIUM BLVD
Second Line	:	SUITE 111
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-4833
Country	:	US
Telephone Number	:	734-665-0074
Fax Number	:	734-665-9383

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	09/11/2025

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