Provider Demographics
NPI:1891028189
Name:BENNER, KAREN ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:ELIZABETH
Last Name:BENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:ELIZABETH
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1611 W HARRISON ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:312-432-2440
Mailing Address - Fax:312-942-1517
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-432-2300
Practice Address - Fax:312-942-1517
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57. 016191207P00000X
IL036-133393207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633878OtherBCBS IL
IL036133393 1Medicaid
IL1633878OtherBCBS IL