Healthcare Provider Details

I. General information

NPI: 1790349033
Provider Name (Legal Business Name): MICHAEL VANANTWERP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E HIGHWAY 50
O FALLON IL
62269-2704
US

IV. Provider business mailing address

320 E HIGHWAY 50
O FALLON IL
62269-2704
US

V. Phone/Fax

Practice location:
  • Phone: 888-577-6337
  • Fax:
Mailing address:
  • Phone: 888-577-6337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.158946
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301506138
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: