Basic Information
| Provider Information | |||||||||
| NPI: | 1376530634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN DORPE | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 DELNOR DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601344220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 DELNOR DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601344220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 01/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036097067 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 206147 | 01 | IL | MEDICARE PTAN (GROUP) | OTHER | 036097067 | 05 | IL | MEDICAID | P00944851 | 01 | IL | RR MEDICARE PTAN (INDIVIDUAL) | OTHER | 206147056 | 01 | IL | MEDICARE PTAN (INDIVIDUAL) | OTHER |