Healthcare Provider Details

I. General information

NPI: 1245222454
Provider Name (Legal Business Name): CARL VANCOL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 111TH ST SUITE 304
CHICAGO IL
60628-4200
US

IV. Provider business mailing address

8646 S SAGINAW AVE
CHICAGO IL
60617-2422
US

V. Phone/Fax

Practice location:
  • Phone: 773-995-3463
  • Fax:
Mailing address:
  • Phone: 773-768-0811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036098516
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number036098516
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036098516
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: