Provider Demographics
NPI:1376595025
Name:BENNETT, ADAM W (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:W
Last Name:BENNETT
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 1:1000 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1658
Mailing Address - Country:US
Mailing Address - Phone:847-535-8500
Mailing Address - Fax:847-535-8488
Practice Address - Street 1:1000 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1658
Practice Address - Country:US
Practice Address - Phone:847-535-8500
Practice Address - Fax:847-535-8488
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106759207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH89386Medicare UPIN
ILK32560Medicare PIN
ILK32561Medicare PIN