Provider Demographics
NPI:1689655391
Name:VAN BERGEN, ANDREW HENRY (MD)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:HENRY
Last Name:VAN BERGEN
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 1:621 PLAINFIELD RD
Mailing Address - Street 2:#105
Mailing Address - City:WILLOW BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5343
Mailing Address - Country:US
Mailing Address - Phone:630-321-9811
Mailing Address - Fax:630-321-9813
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-5580
Practice Address - Fax:708-684-4068
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361074332080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107433Medicaid