Healthcare Provider Details

I. General information

NPI: 1073822573
Provider Name (Legal Business Name): ALYSSA VAN DYK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N INDIAN CANYON DR
PALM SPRINGS CA
92262
US

IV. Provider business mailing address

1600 S INDIANA AVE UNIT 1405
CHICAGO IL
60616-4737
US

V. Phone/Fax

Practice location:
  • Phone: 847-400-4252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number125-056999
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA132809
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: