Provider Demographics
NPI:1356378749
Name:MBA, BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MBA
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 1:1900 W POLK ST
Mailing Address - Street 2:ROOM 1518
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:312-864-7231
Mailing Address - Fax:312-864-9725
Practice Address - Street 1:1901 WEST HARRISON ST
Practice Address - Street 2:JOHN H.STROGER JR. HOSPITAL OF COOK COUNTY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-864-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106690207R00000X
CT73827207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK29812Medicare PIN
IL158593Medicare UPIN