Basic Information
| Provider Information | |||||||||
| NPI: | 1225022312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONALDSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E CHICAGO AVE #9 | ||||||||
| Address2: | ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122273502 | ||||||||
| FaxNumber: | 3122279784 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E CHICAGO AVE # 9 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122273502 | ||||||||
| FaxNumber: | 3122279784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | 036-070919 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | 036-070919 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 036-070919 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 021622158 | 01 | IL | CMMG BLUE SHIELD | OTHER | 036070919 | 05 | IL | MEDICAID |