Provider Demographics
NPI:1679615132
Name:BENEDEK, ELISSA P (MD)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:P
Last Name:BENEDEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2311 E STADIUM BLVD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4833
Mailing Address - Country:US
Mailing Address - Phone:734-665-0074
Mailing Address - Fax:734-665-9383
Practice Address - Street 1:2311 E STADIUM BLVD
Practice Address - Street 2:SUITE 111
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4833
Practice Address - Country:US
Practice Address - Phone:734-665-0074
Practice Address - Fax:734-665-9383
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010242482084P0804X
MIEB0242482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2618102841OtherBCBS PIN
MIBM810164OtherMCARE
MIBM810164OtherMCARE