Provider Demographics
NPI:1134225790
Name:TAIMOORAZY, BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:TAIMOORAZY
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 1:921 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:847-457-3800
Mailing Address - Fax:847-615-2858
Practice Address - Street 1:2203 EASTLAND DR
Practice Address - Street 2:SUITE 7
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7918
Practice Address - Country:US
Practice Address - Phone:309-808-1700
Practice Address - Fax:309-585-2951
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086706207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086706Medicaid
CACB234966Medicare UPIN
IL036086706Medicaid
ILIL5118001Medicare PIN
ILL67149Medicare PIN