Provider Demographics
NPI:1487687810
Name:BENJAKUL, PHILIP SUDCHART (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:SUDCHART
Last Name:BENJAKUL
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 1:312 GRANBY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1466
Mailing Address - Country:US
Mailing Address - Phone:847-208-4268
Mailing Address - Fax:
Practice Address - Street 1:10100 FOREST HILLS RD
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-8234
Practice Address - Country:US
Practice Address - Phone:815-713-2738
Practice Address - Fax:815-282-8597
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106769Medicaid
IL213992Medicare PIN
IL204591Medicare PIN
ILH72498Medicare UPIN
IL834340Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL036106769Medicaid
ILCC5050Medicare ID - Type UnspecifiedRR MEDICARE GROUP #
ILP00194341Medicare ID - Type UnspecifiedRR INDIVIDUAL #