Provider Demographics
NPI:1912912213
Name:HANNA, VAUGHN (MD)
Entity Type:Individual
Prefix:
First Name:VAUGHN
Middle Name:
Last Name:HANNA
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 1:5100 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:309-672-4809
Mailing Address - Fax:
Practice Address - Street 1:120 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-4314
Practice Address - Country:US
Practice Address - Phone:309-671-8270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360885651Medicaid
IL7215059OtherBCBS PPO
IL020755OtherHEALTH ALLIANCE
IL472308OtherHEALTHLINK
ILIL0145OtherJOHN DEERE
IL7215059OtherBCBS PPO
ILIL0145OtherJOHN DEERE