Provider Demographics
NPI:1487657524
Name:VANROEKEL, VIVIAN S (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:S
Last Name:VANROEKEL
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 1:2900 FOXFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-315-6790
Mailing Address - Fax:630-315-6799
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-315-6790
Practice Address - Fax:630-315-6799
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDB1658OtherMEDICARE RAILROAD (GROUP)
IL920540OtherMEDICARE PTAN (GROUP)
ILP01273137OtherMEDICARE RAILROAD (INDIVIDUAL)
IL036064522Medicaid
IL920540026OtherMEDICARE PTAN (INDIVIDUAL)
IL920540026OtherMEDICARE PTAN (INDIVIDUAL)
IL036064522Medicaid