Provider Demographics
NPI:1104094010
Name:WAX, BENJAMIN JASON (PT, DPT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JASON
Last Name:WAX
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-890-5900
Mailing Address - Fax:847-390-4757
Practice Address - Street 1:3936 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2703
Practice Address - Country:US
Practice Address - Phone:630-368-1771
Practice Address - Fax:708-658-2750
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00776867OtherMEDICARE RR
ILP00943153OtherMEDICARE RAILROAD
ILP00684771OtherMEDICARE RR
ILR03938Medicare PIN
ILP00943153OtherMEDICARE RAILROAD
IL216859180Medicare PIN
ILR03939Medicare PIN
ILK53190Medicare PIN
IL214692005Medicare PIN
ILP00776867OtherMEDICARE RR