Basic Information
| Provider Information | |||||||||
| NPI: | 1063439503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O., FACEP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 75 REMIT DRIVE | ||||||||
| Address2: | LOCKBOX 6065 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606756065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669165259 | ||||||||
| FaxNumber: | 2319224030 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 N MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173372000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/04/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-099455 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | H46397 | MD | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | H6194 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | DO20976 | DC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | DO25267 | DC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 5101018060 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 4011 | IA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 0533706 | KS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 34.009604 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1063439503 | 05 | MO | MEDICAID | 1063439503 | 05 | MT | MEDICAID | 5261624 | 01 | MI | BCBS | OTHER | 0036099455 | 05 | IL | MEDICAID | 200604190B | 05 | KS | MEDICAID | 036099455-4 | 05 | IL | MEDICAID | 036099455-5 | 05 | IL | MEDICAID | 036099455-8 | 05 | IL | MEDICAID | 1063439503 | 05 | IA | MEDICAID | 1063439503 | 05 | ID | MEDICAID | EL4268421 | 05 | OH | MEDICAID | 1063439503 | 01 | KS | BLUE SHIELD | OTHER | 1063439503 | 05 | MI | MEDICAID | 1063439503 | 05 | NE | MEDICAID | 2966778 | 05 | OH | MEDICAID | 036099455-7 | 05 | IL | MEDICAID | 036099455-9 | 05 | IL | MEDICAID | 036099455 | 05 | IL | MEDICAID | 1063439503 | 01 | IA | BLUE SHIELD | OTHER | 1063439503 | 05 | WA | MEDICAID |