Basic Information
| Provider Information | |||||||||
| NPI: | 1528182730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 845 SOUTH MAIN STREET | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203220447 | ||||||||
| FaxNumber: | 9203221362 | ||||||||
| Practice Location | |||||||||
| Address1: | 845 SOUTH MAIN STREET | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203220447 | ||||||||
| FaxNumber: | 9203221362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 02/01/2010 | ||||||||
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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 | 225100000X | 5862 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5862-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40308800 | 05 | WI | MEDICAID |