Provider Demographics
NPI:1245222454
Name:VANCOL, CARL (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:VANCOL
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 1:8646 S SAGINAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2422
Mailing Address - Country:US
Mailing Address - Phone:773-768-0811
Mailing Address - Fax:
Practice Address - Street 1:45 W 111TH ST
Practice Address - Street 2:SUITE 304
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4200
Practice Address - Country:US
Practice Address - Phone:773-995-3463
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098516207Q00000X, 207QA0000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Not Answered207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098516Medicaid
IL1625687OtherBCBS ILLINOIS
IL0001633398OtherBLUE CROSS BLUE SHIELD
IL080193944OtherRAILROAD MEDICARE
G85473Medicare UPIN
IL0001633398OtherBLUE CROSS BLUE SHIELD