Healthcare Provider Details

I. General information

NPI: 1134738800
Provider Name (Legal Business Name): BENJAMIN SCOTT HULFACHOR APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4143 N CENTRAL PARK AVE APT G
CHICAGO IL
60618-2062
US

IV. Provider business mailing address

4143 N CENTRAL PARK AVE APT G
CHICAGO IL
60618-2062
US

V. Phone/Fax

Practice location:
  • Phone: 815-616-4559
  • Fax:
Mailing address:
  • Phone: 815-616-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209021004
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: