Provider Demographics
NPI:1285628859
Name:BENGE, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:BENGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:WILLIAM
Other - Last Name:BENGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:800 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1673
Mailing Address - Country:US
Mailing Address - Phone:847-735-8550
Mailing Address - Fax:847-582-2198
Practice Address - Street 1:800 N WESTMORELAND RD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1673
Practice Address - Country:US
Practice Address - Phone:847-735-8550
Practice Address - Fax:847-582-2198
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053646207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053646Medicaid
IL4468170OtherAETNA
IL1699507OtherMPIN
IL1699507OtherMPIN
D43039Medicare UPIN