Provider Demographics
NPI:1518180181
Name:DANIEL J VANDENBERG MD SC
Entity type:Organization
Organization Name:DANIEL J VANDENBERG MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAN OENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-493-1236
Mailing Address - Street 1:71 W 156TH ST
Mailing Address - Street 2:STE 311
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-4260
Mailing Address - Country:US
Mailing Address - Phone:708-339-6321
Mailing Address - Fax:708-339-6326
Practice Address - Street 1:71 W 156TH ST
Practice Address - Street 2:STE 311
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4260
Practice Address - Country:US
Practice Address - Phone:708-339-6321
Practice Address - Fax:708-339-6326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03608859207R00000X
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG12584Medicare UPIN