Healthcare Provider Details

I. General information

NPI: 1992811178
Provider Name (Legal Business Name): TRV - FAMILY MEDICINE, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 W FOSTER AVE SUITE 214
CHICAGO IL
60625-3500
US

IV. Provider business mailing address

2740 W FOSTER AVE SUITE 214
CHICAGO IL
60625-3500
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-2000
  • Fax: 773-506-2668
Mailing address:
  • Phone: 773-506-2000
  • Fax: 773-506-2668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number036092385
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036092385
License Number StateIL

VIII. Authorized Official

Name: DR. TONY R. VANCAUWELAERT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-506-2000