Provider Demographics
NPI:1235768755
Name:VANDERLOO FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:VANDERLOO FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PFH
Authorized Official - Last Name:VANDERLOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-228-5491
Mailing Address - Street 1:3000 OLD CANTON RD STE 240
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4235
Mailing Address - Country:US
Mailing Address - Phone:601-228-5491
Mailing Address - Fax:601-429-9297
Practice Address - Street 1:3000 OLD CANTON RD STE 240
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4235
Practice Address - Country:US
Practice Address - Phone:601-228-5491
Practice Address - Fax:601-429-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty