Healthcare Provider Details

I. General information

NPI: 1992933006
Provider Name (Legal Business Name): BENJAMIN STEVENS BRYNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 19-100
CHICAGO IL
60611-5969
US

IV. Provider business mailing address

1112 HOSP SOUTH GREEN ZONE DUMC 2834
DURHAM NC
27710-0001
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-3278
  • Fax: 312-695-5774
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number201900619
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301094028
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number201600619
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036161012
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: