Healthcare Provider Details

I. General information

NPI: 1063049328
Provider Name (Legal Business Name): RYAN MICHAEL BENNETT HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 W RIDGE RD
ROCHESTER NY
14615-2501
US

IV. Provider business mailing address

1570 W RIDGE RD
ROCHESTER NY
14615-2501
US

V. Phone/Fax

Practice location:
  • Phone: 585-453-2810
  • Fax: 585-453-0759
Mailing address:
  • Phone: 585-453-2810
  • Fax: 585-453-0759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number14000048901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: