Provider Demographics
NPI:1396855185
Name:BENNET, KENNETH G (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:BENNET
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 1:23685 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1236
Mailing Address - Country:US
Mailing Address - Phone:847-677-6410
Mailing Address - Fax:
Practice Address - Street 1:155 E BRUSH HILL RD
Practice Address - Street 2:ELMHURST MEMORIAL HOSPITAL
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5658
Practice Address - Country:US
Practice Address - Phone:630-941-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36116708207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002233091OtherBLUE SHIELD PROVIDER
IL036116708Medicaid
IL214166Medicare ID - Type UnspecifiedILL SOLO MEDICARE #
IL036116708Medicaid