Provider Demographics
NPI:1154454635
Name:DOMB, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:DOMB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 E TOUHY AVE
Mailing Address - Street 2:STE 450
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-2748
Mailing Address - Country:US
Mailing Address - Phone:630-920-2323
Mailing Address - Fax:630-323-5625
Practice Address - Street 1:999 E TOUHY AVE STE 450
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-2748
Practice Address - Country:US
Practice Address - Phone:630-920-2323
Practice Address - Fax:630-323-5625
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119758207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119758Medicaid
IL036119758Medicaid
IL1154454635Medicare UPIN