Healthcare Provider Details

I. General information

NPI: 1093713679
Provider Name (Legal Business Name): LESLIE BENNETT-GRANATA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 HIDDEN MEADOWS DR SUITE 120
HILLSDALE MI
49242-9812
US

IV. Provider business mailing address

12 E BACON ST
HILLSDALE MI
49242-1616
US

V. Phone/Fax

Practice location:
  • Phone: 517-437-0010
  • Fax: 517-437-0319
Mailing address:
  • Phone: 517-437-7010
  • Fax: 517-437-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301075087
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: