Basic Information
| Provider Information | |||||||||
| NPI: | 1851450654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANG | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | EVANSTON HOSPITAL | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701206 | ||||||||
| FaxNumber: | 8475701248 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 N MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600614304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479417600 | ||||||||
| FaxNumber: | 8479417698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2006 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-102927 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.