Provider Demographics
NPI:1720025562
Name:VAN ACKER, TED G (DO)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:G
Last Name:VAN ACKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N PARK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3150
Mailing Address - Country:US
Mailing Address - Phone:618-942-3344
Mailing Address - Fax:618-942-5045
Practice Address - Street 1:220 N PARK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3150
Practice Address - Country:US
Practice Address - Phone:618-942-3344
Practice Address - Fax:618-942-5045
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCB3700OtherRAILROAD MEDICARE GRP #
IL290730OtherHEALTHLINK PROV NUMBER
IL10007459OtherBCBS GROUP NUMBER
ILL84853OtherUMWA PROVIDER NUMBER
IL290730OtherHEALTHLINK PROV NUMBER
IL211499Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILF66682Medicare UPIN
ILL84853Medicare ID - Type UnspecifiedPROV ID