Provider Demographics
NPI:1639397987
Name:MARGOLIS, BEN
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:MARGOLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 N HAZEL ST
Mailing Address - Street 2:#212
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 N HAZEL ST
Practice Address - Street 2:#212
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1289
Practice Address - Country:US
Practice Address - Phone:503-720-6397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH46124Medicare UPIN