Healthcare Provider Details

I. General information

NPI: 1992444368
Provider Name (Legal Business Name): TANNER BENNETT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 S 52ND AVE
OAK LAWN IL
60453-3054
US

IV. Provider business mailing address

9555 S 52ND AVE
OAK LAWN IL
60453-3054
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-5700
  • Fax: 708-422-8225
Mailing address:
  • Phone: 847-224-0143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5151015784
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125086096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: