Healthcare Provider Details

I. General information

NPI: 1891028189
Provider Name (Legal Business Name): KAREN ELIZABETH BENNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAREN ELIZABETH GUSTAFSON M.D.

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST SUITE 400
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

1611 W HARRISON ST STE 400
CHICAGO IL
60612-4861
US

V. Phone/Fax

Practice location:
  • Phone: 312-432-2300
  • Fax: 312-942-1517
Mailing address:
  • Phone: 312-432-2440
  • Fax: 312-942-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number57. 016191
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number036-133393
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: