Healthcare Provider Details

I. General information

NPI: 1083633804
Provider Name (Legal Business Name): BENJAMIN SHAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 S WAUKEGAN RD STE 200
DEERFIELD IL
60015-5204
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-400-8400
  • Fax: 847-400-8445
Mailing address:
  • Phone: 847-570-1206
  • Fax: 847-570-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036103300
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: