Basic Information
| Provider Information | |||||||||
| NPI: | 1366603318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERVLIET | ||||||||
| FirstName: | JON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2006 HOGBACK RD | ||||||||
| Address2: | SUITE 5A | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347862317 | ||||||||
| FaxNumber: | 7347864977 | ||||||||
| Practice Location | |||||||||
| Address1: | 2006 HOGBACK RD | ||||||||
| Address2: | SUITE 5A | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347862317 | ||||||||
| FaxNumber: | 7347864977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 05/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4301092851 | MI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | H17604112 | 01 | MI | MEDICARE PTAN | OTHER | 4301092851 | 01 | MI | MICHIGAN LICENSE | OTHER | 1366603318 | 05 | MI | MEDICAID |