Basic Information
| Provider Information | |||||||||
| NPI: | 1902186166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEHANNI | ||||||||
| FirstName: | MINA | ||||||||
| MiddleName: | MECHEAL BENJAMIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENJAMIN | ||||||||
| OtherFirstName: | MINA | ||||||||
| OtherMiddleName: | MECHEAL | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056850 | ||||||||
| FaxNumber: | 4148056851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2011 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | BP10040686 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 62448 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036152915 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2085U0001X | 036152915 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 207RC0000X | 036.152915 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1902186166 | 05 | WI | MEDICAID |