Healthcare Provider Details

I. General information

NPI: 1104094010
Provider Name (Legal Business Name): BENJAMIN JASON WAX PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3936 N MILWAUKEE AVE
CHICAGO IL
60641-2703
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 630-368-1771
  • Fax: 708-658-2750
Mailing address:
  • Phone: 847-890-5900
  • Fax: 847-390-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070014503
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: