1134392723 NPI number — DR. PAUL ANDREW VANDERLAAN MD, PHD

Table of content: DR. PAUL ANDREW VANDERLAAN MD, PHD (NPI 1134392723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134392723 NPI number — DR. PAUL ANDREW VANDERLAAN MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERLAAN
Provider First Name:
PAUL
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134392723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4833 S WOODLAWN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60615-1919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-924-1398
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 CYPRESS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02445-6002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-582-1193
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)