Provider Demographics
NPI:1902186166
Name:MEHANNI, MINA MECHEAL BENJAMIN (MD, MS)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:MECHEAL BENJAMIN
Last Name:MEHANNI
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:MECHEAL
Other - Last Name:BENJAMIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE FL 4
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6850
Practice Address - Fax:414-805-6851
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10040686207R00000X
WI62448207R00000X
IL036152915207R00000X, 2085U0001X
IL036.152915207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902186166Medicaid