Healthcare Provider Details

I. General information

NPI: 1790410991
Provider Name (Legal Business Name): BENNETT INSTITUTE FOR UROGYNECOLOGY AND INCONTINENCE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 05/27/2024
Certification Date: 05/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-8621
US

IV. Provider business mailing address

770 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-8621
US

V. Phone/Fax

Practice location:
  • Phone: 616-290-1876
  • Fax: 616-290-1877
Mailing address:
  • Phone: 616-290-1876
  • Fax: 616-290-1877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JASON BENNETT
Title or Position: PRESIDENT
Credential: MD
Phone: 616-290-1876