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Individual

STACEY ANNE BENNIS

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
M.D., CAQ-SM

Contact information

Practice address
2160 S 1ST AVE STE 1700, MAYWOOD, IL 60153-3328
(888) 584-7888
Mailing address
2160 S 1ST AVE STE 1700, MAYWOOD, IL 60153-3328
(888) 584-7888

Taxonomy

Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
125-063353
IL
2081S0010X
Sports Medicine (Physical Medicine & Rehabilitation) Physician
Primary
036146120
IL

Other

Enumeration date
06/07/2013
Last updated
10/25/2020
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