MEDICARE: VAN MEDICAL CENTER, INC

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	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1626090	OTHER	IL	BCBS OF IL

General Provider Information

NPI Number	:	1821219551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAN MEDICAL CENTER, INC

Provider Business Mailing Address
First Line	:	3637 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5625
Country	:	US
Telephone Number	:	773-267-2627
Fax Number	:	773-583-8559

Provider Business Practice Location Address
First Line	:	3637 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5625
Country	:	US
Telephone Number	:	773-267-2627
Fax Number	:	773-583-8559

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NGAN T VAN
Credential	:	M.D.
Telephone Number	:	773-267-2627

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	11/27/2007

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