Provider Demographics
NPI:1134119654
Name:BENITO C BAJUYO MD PC
Entity Type:Organization
Organization Name:BENITO C BAJUYO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENITO
Authorized Official - Middle Name:COLANCO
Authorized Official - Last Name:BAJUYO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-524-9232
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:DECKER MEDICAL ANNEX
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-0187
Mailing Address - Country:US
Mailing Address - Phone:618-524-9232
Mailing Address - Fax:618-524-9489
Practice Address - Street 1:28 CHICK ST
Practice Address - Street 2:DECKER MEDICAL ANNEX
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2467
Practice Address - Country:US
Practice Address - Phone:618-524-9232
Practice Address - Fax:618-524-9489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6400025OtherBC IL
262914OtherHLK
262914OtherHLK
299000Medicare ID - Type Unspecified