Provider Demographics
NPI:1164640611
Name:BENNU HEALTH SERVICE
Entity type:Organization
Organization Name:BENNU HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY-WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-354-7572
Mailing Address - Street 1:1125A E HYDE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-2809
Mailing Address - Country:US
Mailing Address - Phone:773-354-7572
Mailing Address - Fax:
Practice Address - Street 1:2617 W 71ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-2003
Practice Address - Country:US
Practice Address - Phone:773-354-7572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH78063Medicare UPIN