Provider Demographics
NPI:1730392044
Name:VANHAZEBROECK, CONRAD GRANT (DO)
Entity type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:GRANT
Last Name:VANHAZEBROECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:847-981-3599
Mailing Address - Fax:
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-981-3599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124591207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program