Provider Demographics
NPI:1376507657
Name:VANDERBILT, JULIE G (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:G
Last Name:VANDERBILT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2426
Mailing Address - Country:US
Mailing Address - Phone:630-469-2000
Mailing Address - Fax:
Practice Address - Street 1:2320 HIGH ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2426
Practice Address - Country:US
Practice Address - Phone:708-388-5500
Practice Address - Fax:708-388-5672
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090162Medicaid
IL080112274OtherRAILROAD MEDICARE
IL375520Medicare PIN
ILG15763Medicare UPIN
IL036090162Medicaid