Provider Demographics
NPI:1568440345
Name:VAN KERREBROECK, DREW R (MD)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:R
Last Name:VAN KERREBROECK
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 1:600 N COLLEGE AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1095
Mailing Address - Country:US
Mailing Address - Phone:309-946-5124
Mailing Address - Fax:309-721-1407
Practice Address - Street 1:600 N COLLEGE AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1095
Practice Address - Country:US
Practice Address - Phone:309-946-5124
Practice Address - Fax:309-721-1407
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106649207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00024916OtherRR MEDICARE
IL1568440345Medicaid
IL036106649Medicaid
ILL98552Medicare PIN
H83610Medicare UPIN