Healthcare Provider Details

I. General information

NPI: 1013234707
Provider Name (Legal Business Name): BRADLEY BENGTSON, M.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MIDTOWNE ST NE SUITE 110
GRAND RAPIDS MI
49503-5729
US

IV. Provider business mailing address

555 MIDTOWNE ST NE SUITE 110
GRAND RAPIDS MI
49503-5729
US

V. Phone/Fax

Practice location:
  • Phone: 616-588-8880
  • Fax: 616-588-8881
Mailing address:
  • Phone: 616-588-8880
  • Fax: 616-588-8881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301407033
License Number StateMI

VIII. Authorized Official

Name: DR. BRADLEY BENGTSON
Title or Position: OWNER
Credential: M.D., FACS
Phone: 616-588-8880