Individual
BENJAMIN ILLICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(228) 984-5582
Mailing address
2500 N STATE ST, JACKSON, MS 39216-4500
(228) 984-5582
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
24710
MS
390200000X
Student in an Organized Health Care Education/Training Program
390200000
MS
Other
Enumeration date
05/12/2014
Last updated
02/04/2022
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