MEDICARE: DR. ANTHONY ARLO BENNETT 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	2085R0202X	Diagnostic Radiology Physician	AB063302	MI
2	2085R0202X	Diagnostic Radiology Physician	036112710	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AB063302	OTHER	MI	LICENSE
2	700H219330	OTHER	MI	BLUE CROSS
3	3009301771	OTHER	MI	BCBSM
4	MI3594001	OTHER	MI	PTAN

General Provider Information

NPI Number	:	1801866397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTHONY ARLO BENNETT MD

Provider Business Mailing Address
First Line	:	441 FRANKLIN WRIGHT BLVD
Second Line	:
City	:	LAKE ORION
State	:	MI
Zip	:	48362-1585
Country	:	US
Telephone Number	:	248-894-8019
Fax Number	:	248-693-4632

Provider Business Practice Location Address
First Line	:	1899 ORCHARD LAKE RD
Second Line	:	SUITE 104
City	:	SYLVAN LAKE
State	:	MI
Zip	:	48320-1774
Country	:	US
Telephone Number	:	248-894-8019
Fax Number	:	248-693-4632

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

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	11/13/2023

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