Provider Demographics
NPI:1730538414
Name:YOURCHOCK, BENJAMIN P (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:P
Last Name:YOURCHOCK
Suffix:
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 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 MICHIGAN STREET
Practice Address - Street 2:
Practice Address - City:WALKERTON
Practice Address - State:IN
Practice Address - Zip Code:46574-1116
Practice Address - Country:US
Practice Address - Phone:574-335-5200
Practice Address - Fax:574-335-0858
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01082203A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201376710Medicaid
IN1102538181OtherANTHEM