Basic Information
| Provider Information | |||||||||
| NPI: | 1285643825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOCK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 E SEIBERLING ST | ||||||||
| Address2: | |||||||||
| City: | BLUE MOUND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625130260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176922151 | ||||||||
| FaxNumber: | 2176922121 | ||||||||
| Practice Location | |||||||||
| Address1: | 4965 E LOST BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625215139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178645531 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-077533 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-077533 | 05 | IL | MEDICAID | 036-077533 | 01 | IL | STATE LICENSE | OTHER | BB1601031 | 01 | DEA - CONTROLLED SUBSTANC | OTHER |