Provider Demographics
NPI:1932182326
Name:VANDENBERG, JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:VANDENBERG
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 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-277-3960
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036166619207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1193995Medicaid
IA49079OtherBX
F72480Medicare UPIN
IA49079Medicare ID - Type Unspecified