Healthcare Provider Details

I. General information

NPI: 1699193334
Provider Name (Legal Business Name): BENJAMIN C GARDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 GOLF RD
SKOKIE IL
60076
US

IV. Provider business mailing address

4605 GOLF RD
SKOKIE IL
60076-1209
US

V. Phone/Fax

Practice location:
  • Phone: 847-679-5199
  • Fax: 847-679-5490
Mailing address:
  • Phone: 847-679-5199
  • Fax: 847-679-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036145621
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036145621
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: