=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760627137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID J. BENDITZSON, M.D., LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2008
-----------------------------------------------------
Last Update Date | 12/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 E WASHINGTON ST STE 2903
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-2268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-266-1222
-----------------------------------------------------
Fax | 312-541-2810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 E WASHINGTON ST STE 2903
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-2268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-266-1222
-----------------------------------------------------
Fax | 312-541-2810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID JEROME BENDITZSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 312-266-1222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 036040406
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------