Healthcare Provider Details

I. General information

NPI: 1689655391
Provider Name (Legal Business Name): ANDREW HENRY VAN BERGEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

621 PLAINFIELD RD #105
WILLOW BROOK IL
60527-5343
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5580
  • Fax: 708-684-4068
Mailing address:
  • Phone: 630-321-9811
  • Fax: 630-321-9813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number036107433
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: