Healthcare Provider Details

I. General information

NPI: 1366072555
Provider Name (Legal Business Name): BENEDICTINE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 COLLEGE RD
LISLE IL
60532-2851
US

IV. Provider business mailing address

5700 COLLEGE RD
LISLE IL
60532-2851
US

V. Phone/Fax

Practice location:
  • Phone: 630-829-6154
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. NATHAN VANRADEN
Title or Position: ASSISTANT AD/HEAD ATHLETIC TRAINER
Credential: ATC
Phone: 630-829-6154