Provider Demographics
NPI:1679653083
Name:BENSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N MONROE
Mailing Address - Street 2:
Mailing Address - City:ABINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61401
Mailing Address - Country:US
Mailing Address - Phone:309-462-2343
Mailing Address - Fax:309-462-2833
Practice Address - Street 1:100 N MONROE
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:IL
Practice Address - Zip Code:61401
Practice Address - Country:US
Practice Address - Phone:309-462-2343
Practice Address - Fax:309-462-2833
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041191193/08500303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL833610Medicare ID - Type UnspecifiedGROUP #
ILCB6569Medicare ID - Type UnspecifiedRR GROUP #
ILK36104Medicare ID - Type UnspecifiedINDIVIDUAL #
S78900Medicare UPIN
IL539060Medicare ID - Type UnspecifiedINDIVIDUAL #