Provider Demographics
NPI:1790872851
Name:LAURA VAN DUSEN M.D. S.C.
Entity Type:Organization
Organization Name:LAURA VAN DUSEN M.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:VAN DUSEN
Authorized Official - Last Name:VAN DUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-296-3442
Mailing Address - Street 1:1440 RENAISSANCE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1356
Mailing Address - Country:US
Mailing Address - Phone:847-296-3442
Mailing Address - Fax:847-296-3543
Practice Address - Street 1:1440 RENAISSANCE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1356
Practice Address - Country:US
Practice Address - Phone:847-296-3442
Practice Address - Fax:847-296-3543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2010-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361031372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH49197Medicare UPIN
IL633600Medicare ID - Type Unspecified