Healthcare Provider Details

I. General information

NPI: 1093545642
Provider Name (Legal Business Name): BENJAMIN EJZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 N OAKLEY BLVD FL 3
CHICAGO IL
60622-3507
US

IV. Provider business mailing address

1127 N OAKLEY BLVD FL 3
CHICAGO IL
60622-3507
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2317
  • Fax:
Mailing address:
  • Phone: 312-770-2317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: