Provider Demographics
NPI:1780747329
Name:ANDERSON, BENITA (MD)
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:666 DUNDEE RD STE 1302
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2736
Mailing Address - Country:US
Mailing Address - Phone:847-400-5133
Mailing Address - Fax:847-400-5828
Practice Address - Street 1:666 DUNDEE RD STE 1302
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2736
Practice Address - Country:US
Practice Address - Phone:847-400-5133
Practice Address - Fax:847-400-5828
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0756542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry