Basic Information
| Provider Information | |||||||||
| NPI: | 1053564617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENBOW | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD A201 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 13750 S SEDONA PKWY | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489068101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176699758 | ||||||||
| FaxNumber: | 5176798232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35.095877 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4301104293 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 35.095877 | 01 | OH | OHIO STATE MEDICAL LICENSE | OTHER | 57-014989 | 01 | OH | TRAINING CERTIFICATE | OTHER | FB2470843 | 01 | DEA | OTHER | 4301104293 | 01 | MI | MI MEDICAL LICENSE | OTHER | 1053564617 | 05 | MI | MEDICAID |