Healthcare Provider Details

I. General information

NPI: 1356378749
Provider Name (Legal Business Name): BENJAMIN MBA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 WEST HARRISON ST JOHN H.STROGER JR. HOSPITAL OF COOK COUNTY
CHICAGO IL
60612
US

IV. Provider business mailing address

1900 W POLK ST ROOM 1518
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 312-864-7231
  • Fax: 312-864-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-106690
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number73827
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: