Basic Information
| Provider Information | |||||||||
| NPI: | 1225096795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANVLECK | ||||||||
| FirstName: | MATHEW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 PEELER ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490082300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693458618 | ||||||||
| FaxNumber: | 2693451508 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 PEELER ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490082300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693458618 | ||||||||
| FaxNumber: | 2693451508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4301061951 | MI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 4301061951 | 01 | MI | MI LICENSE | OTHER |