MEDICARE: BENJAMIN SHAIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	036103300	IL

General Provider Information

NPI Number	:	1083633804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN SHAIN MD

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1718
Country	:	US
Telephone Number	:	847-570-1206
Fax Number	:	847-570-1248

Provider Business Practice Location Address
First Line	:	49 S WAUKEGAN RD STE 200
Second Line	:
City	:	DEERFIELD
State	:	IL
Zip	:	60015-5204
Country	:	US
Telephone Number	:	847-400-8400
Fax Number	:	847-400-8445

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	12/08/2020

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