Healthcare Provider Details

I. General information

NPI: 1891339487
Provider Name (Legal Business Name): VANGUARD ELDERCARE MEDICAL GROUP - ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 RENAISSANCE CIR
HOMER GLEN IL
60491-5891
US

IV. Provider business mailing address

2100 N MAIN ST STE 301 ONE PROFESSIONAL CENTER
CROWN POINT IN
46307-1877
US

V. Phone/Fax

Practice location:
  • Phone: 574-546-1900
  • Fax: 574-546-1999
Mailing address:
  • Phone: 574-546-1900
  • Fax: 574-546-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STEVEN L POSAR
Title or Position: PRESIDENT
Credential:
Phone: 574-546-1900