Provider Demographics
NPI:1962695619
Name:VAN ORTHOPAEDIC & SPINE SURGERY
Entity type:Organization
Organization Name:VAN ORTHOPAEDIC & SPINE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:U
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-561-1708
Mailing Address - Street 1:422 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068
Mailing Address - Country:US
Mailing Address - Phone:815-561-1708
Mailing Address - Fax:815-561-8209
Practice Address - Street 1:422 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068
Practice Address - Country:US
Practice Address - Phone:815-561-1708
Practice Address - Fax:815-561-8209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7126180OtherBCBS
IL213085Medicare PIN
ILK25406Medicare UPIN