Provider Demographics
NPI:1700380128
Name:SAIYASOMBAT, BEN (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:SAIYASOMBAT
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 1:2650 N LAKEVIEW AVE APT 3101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072283207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine