Healthcare Provider Details

I. General information

NPI: 1003852161
Provider Name (Legal Business Name): ELIZA A. BENNETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 S PARK ST OB/GYN CLINIC
MADISON WI
53715-1348
US

IV. Provider business mailing address

1 SOUTH PARK SUITE 555 UNIVERSITY OF WISCONSIN DEPARTMENT OF OB/GYN
MADISON WI
53715-1349
US

V. Phone/Fax

Practice location:
  • Phone: 608-287-2830
  • Fax:
Mailing address:
  • Phone: 608-287-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number51413-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: