MEDICARE: BENNETT S WALSTATTER 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	207V00000X	Obstetrics & Gynecology Physician	BW064603	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912092172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENNETT S WALSTATTER MD

Provider Business Mailing Address
First Line	:	1202 W OAK ST
Second Line	:
City	:	GREENVILLE
State	:	MI
Zip	:	48838-2155
Country	:	US
Telephone Number	:	616-754-2944
Fax Number	:	616-754-2999

Provider Business Practice Location Address
First Line	:	1202 W OAK ST
Second Line	:
City	:	GREENVILLE
State	:	MI
Zip	:	48838-2155
Country	:	US
Telephone Number	:	616-754-2944
Fax Number	:	616-754-2999

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	05/31/2012

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