Healthcare Provider Details

I. General information

NPI: 1174254247
Provider Name (Legal Business Name): BENJAMIN HAHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 ELIZABETH FLD
GERMANTOWN HILLS IL
61548-9476
US

IV. Provider business mailing address

501 ELIZABETH FLD
GERMANTOWN HILLS IL
61548-9476
US

V. Phone/Fax

Practice location:
  • Phone: 309-357-2931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119436
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009585
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: