Healthcare Provider Details

I. General information

NPI: 1821193491
Provider Name (Legal Business Name): MICHELLE A. BENSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34700 VALLEY RD
OCONOMOWOC WI
53066-4500
US

IV. Provider business mailing address

34700 VALLEY RD
OCONOMOWOC WI
53066-4500
US

V. Phone/Fax

Practice location:
  • Phone: 262-646-4411
  • Fax: 262-646-1049
Mailing address:
  • Phone: 262-646-4411
  • Fax: 262-646-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number38279
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number38279
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number38279
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: