Basic Information
| Provider Information | |||||||||
| NPI: | 1528172889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRANTLY | ||||||||
| FirstName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2449 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174721148 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 W JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461312140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174721148 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01021769 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100047750 | 05 | IN | MEDICAID |