MEDICARE: JOEL BENJAMIN DINVERNO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	4301073676	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3503810581	OTHER	MI	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104865633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL BENJAMIN DINVERNO MD

Provider Business Mailing Address
First Line	:	11755 E MICHIGAN AVE
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9219
Country	:	US
Telephone Number	:	517-522-6100
Fax Number	:	517-522-4715

Provider Business Practice Location Address
First Line	:	11755 E MICHIGAN AVE
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9219
Country	:	US
Telephone Number	:	517-522-6100
Fax Number	:	517-522-4715

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	01/26/2009

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