Healthcare Provider Details

I. General information

NPI: 1902186166
Provider Name (Legal Business Name): MINA MECHEAL BENJAMIN MEHANNI MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MINA MECHEAL BENJAMIN

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE FL 4
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

PO BOX 959354
SAINT LOUIS MO
63195-9354
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-6850
  • Fax: 414-805-6851
Mailing address:
  • Phone: 636-916-7272
  • Fax: 636-916-7274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10040686
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number62448
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036152915
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2022045774
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number036152915
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: