Healthcare Provider Details

I. General information

NPI: 1336482348
Provider Name (Legal Business Name): BENJAMIN CARNEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 W 95TH ST
EVERGREEN PARK IL
60805
US

IV. Provider business mailing address

2800 W 95TH ST
EVERGREEN PARK IL
60805-2701
US

V. Phone/Fax

Practice location:
  • Phone: 708-229-5652
  • Fax:
Mailing address:
  • Phone: 773-320-0066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301114604
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036149841
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: