Basic Information
| Provider Information | |||||||||
| NPI: | 1831689702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 HARVESTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605275965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737021150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2650 RIDGE AVE STE 1304 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 06/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 036-155845 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 125071891 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036.155845 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.