Provider Demographics
NPI:1366435224
Name:VANLE, JESSE L (MD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:L
Last Name:VANLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1505 EASTLAND DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7906
Mailing Address - Country:US
Mailing Address - Phone:309-662-5506
Mailing Address - Fax:309-662-5443
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7906
Practice Address - Country:US
Practice Address - Phone:309-662-5506
Practice Address - Fax:309-662-5443
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109293208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204597405Medicaid
2299329OtherUNITED HEALTHCARE
37875OtherPHCS
IL0106OtherJOHN DEERE HEALTH PLAN
036109293001OtherOSF HEALTH PLANS
IL084529OtherHEALTH ALLIANCE PROVIDER
IL036109293Medicaid
IL05732036OtherBLUE SHIELD GROUP NUMBER
566399OtherHEALTHLINK
37972OtherTRICARE
276560OtherPERSONAL CARE
37972OtherTRICARE
ILL98313Medicare PIN
566399OtherHEALTHLINK