Basic Information
| Provider Information | |||||||||
| NPI: | 1881618205 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BENDER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 DEVON DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488809428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066430463 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 BURDETTE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066430463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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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 | 207P00000X | 4301074016 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 4301074016 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4482131 | 05 | MI | MEDICAID |