Healthcare Provider Details

I. General information

NPI: 1366239899
Provider Name (Legal Business Name): JUSTIN GORDON BENNIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4717 SAINT ANTOINE ST
DETROIT MI
48201-1423
US

IV. Provider business mailing address

14091 MERCI AVE
STERLING HEIGHTS MI
48313-5586
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-8900
  • Fax:
Mailing address:
  • Phone: 586-295-7031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: