Basic Information
| Provider Information | |||||||||
| NPI: | 1972618734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SACKETT | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 S CLAY STREET | ||||||||
| Address2: | SUITE 246E | ||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303232229 | ||||||||
| FaxNumber: | 6303235011 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 N MILL ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605636304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306468000 | ||||||||
| FaxNumber: | 6306468007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 11/23/2010 | ||||||||
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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 | 2084P0800X | 036047726 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036047726 1 | 05 | IL | MEDICAID |