Provider Demographics
NPI:1104014075
Name:ALLISON BENTHAL D.O. S.C.
Entity Type:Organization
Organization Name:ALLISON BENTHAL D.O. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-381-1004
Mailing Address - Street 1:5727 STRATHMOOR DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5180
Mailing Address - Country:US
Mailing Address - Phone:815-381-1004
Mailing Address - Fax:815-381-1007
Practice Address - Street 1:1893 DAIMLER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1081
Practice Address - Country:US
Practice Address - Phone:815-381-1004
Practice Address - Fax:815-381-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210143Medicare PIN