MEDICARE: DR. JEFFREY M VANBENDEGOM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	43485	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	43485	OTHER	WI	MD LICENSE

General Provider Information

NPI Number	:	1477544427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY M VANBENDEGOM M.D.

Provider Business Mailing Address
First Line	:	3801 SPRING ST
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-1667
Country	:	US
Telephone Number	:	262-687-4479
Fax Number	:	262-687-4479

Provider Business Practice Location Address
First Line	:	3801 SPRING ST
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-1667
Country	:	US
Telephone Number	:	262-687-4479
Fax Number	:	262-687-5375

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/09/2007

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