Basic Information
| Provider Information | |||||||||
| NPI: | 1487687810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAKUL | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | SUDCHART | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 GRANBY RD | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600451466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472084268 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10100 FOREST HILLS RD | ||||||||
| Address2: | |||||||||
| City: | MACHESNEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611158234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157132738 | ||||||||
| FaxNumber: | 8152828597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 12/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036106769 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036106769 | 05 | IL | MEDICAID |