Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036098516 | IL |
N | 207QA0505X | Family Doctor - Adult Medicine | 036098516 | IL |
NPI | 1245222454 |
---|---|
Provider Name | Carl Vancol |
First Address | Chicago, IL 60617-2422 |
Second Address | Chicago, IL 60628-4200 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0001633398 | BLUE CROSS BLUE SHIELD (01) | IL |
036098516 | (05) | IL |
080193944 | RAILROAD MEDICARE (01) | IL |
1625687 | BCBS ILLINOIS (01) | IL |
G85473 | (02) |