Basic Information
| Provider Information | |||||||||
| NPI: | 1982678553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANBLARCOM | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | THADDEUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1126 S 70TH STREET | ||||||||
| Address2: | SUITE N500 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144554780 | ||||||||
| FaxNumber: | 4144752936 | ||||||||
| Practice Location | |||||||||
| Address1: | 10400 W NORTH AVENUE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147717470 | ||||||||
| FaxNumber: | 4147717433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 28611-020 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 31516400 | 05 | WI | MEDICAID |