Basic Information
| Provider Information | |||||||||
| NPI: | 1861562985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDER LUGT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3621 SOUTH STATE STREET | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 EAST MEDICAL CENTER DRIVE | ||||||||
| Address2: | 7TH FLOOR C.S. MOTT CHILDRENS HOSPITAL | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481094257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349369814 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | MD446513 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0207X | 4301094130 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 4301094130 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.