Provider Demographics
NPI:1497774459
Name:LUM, BENNETT (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:
Last Name:LUM
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 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:2800 W 95TH STREET
Practice Address - Street 2:LITTLE COMPANY OF MARY HOSPITAL
Practice Address - City:EVERGREEN
Practice Address - State:IL
Practice Address - Zip Code:60805
Practice Address - Country:US
Practice Address - Phone:708-229-5104
Practice Address - Fax:630-323-1699
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360828572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082857Medicaid
0221524519OtherBCBS
300125827OtherRR MED #