Healthcare Provider Details

I. General information

NPI: 1124522537
Provider Name (Legal Business Name): BENJAMIN BRYAN GOLDENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

9923 TANGLEWOOD CT
MUNSTER IN
46321-3840
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 219-680-0673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number036-155197
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: