Provider Demographics
NPI:1366072555
Name:BENEDICTINE UNIVERSITY
Entity type:Organization
Organization Name:BENEDICTINE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT AD/HEAD ATHLETIC TRAINER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANRADEN
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:630-829-6154
Mailing Address - Street 1:5700 COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5700 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-2851
Practice Address - Country:US
Practice Address - Phone:630-829-6154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENEDICTINE ATHLETIC REHAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty