Healthcare Provider Details

I. General information

NPI: 1881898617
Provider Name (Legal Business Name): BENEDICT E CISZEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE STE 121
CHICAGO IL
60631-3712
US

IV. Provider business mailing address

7447 W TALCOTT AVE STE 121
CHICAGO IL
60631-3712
US

V. Phone/Fax

Practice location:
  • Phone: 773-990-3900
  • Fax: 773-990-3929
Mailing address:
  • Phone: 773-990-3900
  • Fax: 773-990-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.117812
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: