Provider Demographics
NPI:1184056624
Name:ANDERSON, BENJAMIN H (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:H
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 BIESTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3306
Mailing Address - Country:US
Mailing Address - Phone:847-690-1776
Mailing Address - Fax:847-690-1777
Practice Address - Street 1:555 BIESTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3306
Practice Address - Country:US
Practice Address - Phone:847-690-1776
Practice Address - Fax:847-690-1777
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002720A363A00000X
IL085004742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001291751OtherANTHEM PTAN
IN300027244Medicaid
IN000001291563OtherANTHEM PTAN