Basic Information
| Provider Information | |||||||||
| NPI: | 1932313574 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31157 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483360123 | ||||||||
| FaxNumber: | 2483363190 | ||||||||
| Practice Location | |||||||||
| Address1: | 31157 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483360123 | ||||||||
| FaxNumber: | 2483363190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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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 | 208800000X | 4301080053 | MI | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | P00761477 | 01 | MI | RAILROAD MEDICARE | OTHER | 0E06273 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |