Healthcare Provider Details

I. General information

NPI: 1316994213
Provider Name (Legal Business Name): ANTHONY A BENNETT M D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29777 TELEGRAPH RD
SOUTHFIELD MI
48034-7625
US

IV. Provider business mailing address

441 FRANKLIN WRIGHT BLVD
LAKE ORION MI
48362-1585
US

V. Phone/Fax

Practice location:
  • Phone: 248-894-8019
  • Fax: 248-799-0473
Mailing address:
  • Phone: 248-894-8019
  • Fax: 248-799-0473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberAB063302
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberAB063302
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberAB063302
License Number StateMI

VIII. Authorized Official

Name: DR. ANTHONY A BENNETT
Title or Position: RADIOLOGIST
Credential: MD
Phone: 248-894-8019