Provider Demographics
NPI:1720475585
Name:BEN MOHA, RAYNA (MD)
Entity Type:Individual
Prefix:
First Name:RAYNA
Middle Name:
Last Name:BEN MOHA
Suffix:
Gender:F
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 RIDGE AVE STE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-982-6715
Mailing Address - Fax:847-982-3394
Practice Address - Street 1:5145 N CALIFORNIA AVE STE 331
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:773-989-1734
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021196363L00000X
WAAP60677447363LF0000X
390200000X
IL125080199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1720475585Medicaid
WAP01744079OtherRR MEDICARE WVH
WAG8959165, G8959166Medicare PIN