Basic Information
| Provider Information | |||||||||
| NPI: | 1699715615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 JOLIET ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198643300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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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 | 225100000X | 05008615A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01062367 | 01 | IN | MEDICARE RAILROAD | OTHER | 000000363564 | 01 | IN | ANTHEM - APT PLUS | OTHER | 000000363578 | 01 | IN | ANTHEM - 1ST AID PLUS | OTHER | 000000363579 | 01 | IN | ANTHEM - MBWOUDE | OTHER |