Provider Demographics
NPI:1063497386
Name:VANDERSCHAAF, LYLE J (MD)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:J
Last Name:VANDERSCHAAF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 DEPT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-4821
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:420 W MAGNETIC ST
Practice Address - Street 2:SUITE ER
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2711
Practice Address - Country:US
Practice Address - Phone:888-674-0854
Practice Address - Fax:906-225-3370
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070441207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301070441OtherMICHIGAN LICENSE #
MI4301070441OtherMICHIGAN LICENSE #
MI0M36120016Medicare PIN