Healthcare Provider Details

I. General information

NPI: 1104865633
Provider Name (Legal Business Name): JOEL BENJAMIN DINVERNO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11755 E MICHIGAN AVE
GRASS LAKE MI
49240-9219
US

IV. Provider business mailing address

11755 E MICHIGAN AVE
GRASS LAKE MI
49240-9219
US

V. Phone/Fax

Practice location:
  • Phone: 517-522-6100
  • Fax: 517-522-4715
Mailing address:
  • Phone: 517-522-6100
  • Fax: 517-522-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301073676
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: