=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417061722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK VANDRUNEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HINES VA HOSPITAL 5TH AVE & ROOSEVELT ROAD
-----------------------------------------------------
City | HINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-202-2169
-----------------------------------------------------
Fax | 708-202-2292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 BRIARWOOD LN
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-8706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-321-1944
-----------------------------------------------------
Fax | 708-202-2292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------