Healthcare Provider Details

I. General information

NPI: 1376577841
Provider Name (Legal Business Name): GREGORY C. VACHON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4259 S BERKELEY AVE KOMED HEALTH CENTER
CHICAGO IL
60653-3030
US

IV. Provider business mailing address

846 N OAK PARK AVE
OAK PARK IL
60302-1539
US

V. Phone/Fax

Practice location:
  • Phone: 312-285-7678
  • Fax:
Mailing address:
  • Phone: 708-763-9580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036089597
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: