Basic Information
| Provider Information | |||||||||
| NPI: | 1316930670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481041902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346655306 | ||||||||
| FaxNumber: | 7349302383 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481041902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346655306 | ||||||||
| FaxNumber: | 7349302383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 02/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002604 | MI | Y | Eye and Vision Services Providers | Optometrist | 152WC0802X | 4901002604 | MI | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WL0500X | 4901002604 | MI | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152WP0200X | 4901002604 | MI | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WX0102X | 4901002604 | MI | N | Eye and Vision Services Providers | Optometrist | Occupational Vision |
ID Information
| ID | Type | State | Issuer | Description | 2675077 | 05 | MI | MEDICAID | SB002604 | 01 | MI | BCBS MICHIGAN | OTHER |