Provider Demographics
NPI:1518917046
Name:GOLDBERG, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:GOLDBERG
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 1:835 S WOLCOTT AVE
Mailing Address - Street 2:M/C 844
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3748
Mailing Address - Country:US
Mailing Address - Phone:312-996-7161
Mailing Address - Fax:312-996-9025
Practice Address - Street 1:835 S WOLCOTT AVE
Practice Address - Street 2:M/C 844
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3748
Practice Address - Country:US
Practice Address - Phone:312-996-7161
Practice Address - Fax:312-996-9025
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-100126207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-100126-2Medicaid
IL036-100126-2Medicaid
ILK26776 / 357801Medicare ID - Type Unspecified