Provider Demographics
NPI:1366529240
Name:BENNETT, NELSON E JR (MD)
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:E
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 20-150
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5979
Mailing Address - Country:US
Mailing Address - Phone:312-695-8146
Mailing Address - Fax:312-695-7030
Practice Address - Street 1:675 N SAINT CLAIR ST STE 20-150
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5979
Practice Address - Country:US
Practice Address - Phone:312-695-8146
Practice Address - Fax:312-695-7030
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036140620208800000X, 208800000X
MA233178208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110077210AMedicaid
NY4S3451OtherMEDICARE ID
MA110077210AMedicaid
MA000178302Medicare PIN