Provider Demographics
NPI:1740201060
Name:MARTA BANEGAS, M.D.
Entity Type:Organization
Organization Name:MARTA BANEGAS, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-767-8283
Mailing Address - Street 1:PO BOX 388320
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-8320
Mailing Address - Country:US
Mailing Address - Phone:776-767-4600
Mailing Address - Fax:773-767-4600
Practice Address - Street 1:917 N LA SALLE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-3204
Practice Address - Country:US
Practice Address - Phone:773-767-8283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1618837OtherBLUE SHIELD