Healthcare Provider Details

I. General information

NPI: 1245541374
Provider Name (Legal Business Name): MOR BEN BARAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E SUPERIOR ST FL 12
CHICAGO IL
60611-4494
US

IV. Provider business mailing address

5616 N WINTHROP AVE APT 1F
CHICAGO IL
60660-4420
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-7975
  • Fax:
Mailing address:
  • Phone: 708-691-7706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036138016
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125058326
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: