Provider Demographics
NPI:1356495030
Name:DUBIN, BENJAMIN A (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:A
Last Name:DUBIN
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 1:103 S GREENLEAF ST
Mailing Address - Street 2:SUITE J
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3380
Mailing Address - Country:US
Mailing Address - Phone:847-662-8201
Mailing Address - Fax:847-662-8215
Practice Address - Street 1:103 S GREENLEAF ST
Practice Address - Street 2:SUITE J
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3380
Practice Address - Country:US
Practice Address - Phone:847-662-8201
Practice Address - Fax:847-662-8215
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360399611Medicaid
IL453550OtherMEDICARE GRP NUMBER
IL1609827237OtherNPI PRACTICE NUMBER
ILK39550OtherMDR INDIVIDUAL NUMBER
IL4920144OtherBCBS PROVIDER #
IL4392571OtherAETNA PROVIDER NUMBER
IL7248829002OtherCIGNA PROVIDER NUMBER
IL1609827237OtherNPI PRACTICE NUMBER
IL906270Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER