Provider Demographics
NPI:1275623050
Name:WREN, BENEDICTA (MD)
Entity Type:Individual
Prefix:
First Name:BENEDICTA
Middle Name:
Last Name:WREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 N LAKE SHORE DR
Mailing Address - Street 2:5A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1626
Mailing Address - Country:US
Mailing Address - Phone:312-642-9476
Mailing Address - Fax:
Practice Address - Street 1:1239 W 18TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3242
Practice Address - Country:US
Practice Address - Phone:312-738-3111
Practice Address - Fax:312-738-2577
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036045400Medicaid
IL530190Medicare ID - Type Unspecified
ILF72386Medicare UPIN