Basic Information
| Provider Information | |||||||||
| NPI: | 1093726226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | NELSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 S HIGHLAND WAY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295723362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434574747 | ||||||||
| FaxNumber: | 8434976405 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
| FaxNumber: | 6184570469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036082903 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 16733 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 62661 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 167330 | 05 | SC | MEDICAID |