Healthcare Provider Details

I. General information

NPI: 1548377252
Provider Name (Legal Business Name): MICHELLE BENE BAIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S WOOD ST RM 376
CHICAGO IL
60612-7300
US

IV. Provider business mailing address

4500 W BERTEAU AVE
CHICAGO IL
60641-1908
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-6966
  • Fax: 312-996-1188
Mailing address:
  • Phone: 773-283-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: