Provider Demographics
NPI:1639338254
Name:BENJAMIN SAMUEL MD S C
Entity Type:Organization
Organization Name:BENJAMIN SAMUEL MD S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-220-3972
Mailing Address - Street 1:533 W BARRY AVE APT 16F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5475
Mailing Address - Country:US
Mailing Address - Phone:773-220-3972
Mailing Address - Fax:
Practice Address - Street 1:2525 S MICHIGAN AVE MAIL BOX 216
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-5475
Practice Address - Country:US
Practice Address - Phone:773-220-3972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094563207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
IL216995Medicare PIN
IL216990Medicare PIN