Provider Demographics
NPI:1164554473
Name:MATSUMOTO, BENJAMIN (MD)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:MATSUMOTO
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 1:2900 N LAKE SHORE DR
Mailing Address - Street 2:MEDICAL STAFF OFFICE PRESENCE ST. JOSEPH HOSPITAL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5640
Mailing Address - Country:US
Mailing Address - Phone:773-665-3000
Mailing Address - Fax:
Practice Address - Street 1:2900 N LAKE SHORE DR
Practice Address - Street 2:MEDICAL STAFF OFFICE PRESENCE ST. JOSEPH HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5640
Practice Address - Country:US
Practice Address - Phone:773-665-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 063322174400000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC46227Medicare UPIN
IL738210Medicare PIN