Healthcare Provider Details

I. General information

NPI: 1063488898
Provider Name (Legal Business Name): CHARLES BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST GALTER 21-100
CHICAGO IL
60611-5975
US

IV. Provider business mailing address

680 N LAKE SHORE DR SUITE 1000
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6180
  • Fax:
Mailing address:
  • Phone: 312-695-9797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036-065474
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: