Provider Demographics
NPI:1477547388
Name:VANDERBILT, BRIAN DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DALE
Last Name:VANDERBILT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 SUMMERHILL DR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-4556
Mailing Address - Country:US
Mailing Address - Phone:847-719-2225
Mailing Address - Fax:847-719-2527
Practice Address - Street 1:40 LANDOVER PKWY
Practice Address - Street 2:
Practice Address - City:HAWTHORN WOODS
Practice Address - State:IL
Practice Address - Zip Code:60047-7508
Practice Address - Country:US
Practice Address - Phone:847-719-2225
Practice Address - Fax:847-719-2527
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04932406OtherBCBSIL PIN #
IL210044Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #