Provider Demographics
NPI:1992811178
Name:TRV - FAMILY MEDICINE, LTD.
Entity type:Organization
Organization Name:TRV - FAMILY MEDICINE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANCAUWELAERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-506-2000
Mailing Address - Street 1:2740 W FOSTER AVE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3500
Mailing Address - Country:US
Mailing Address - Phone:773-506-2000
Mailing Address - Fax:773-506-2668
Practice Address - Street 1:2740 W FOSTER AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3500
Practice Address - Country:US
Practice Address - Phone:773-506-2000
Practice Address - Fax:773-506-2668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092385207Q00000X, 207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092385Medicaid
200225Medicare ID - Type Unspecified
ILG40625Medicare UPIN