Basic Information
| Provider Information | |||||||||
| NPI: | 1598741050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAMES | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10660 W 143RD ST | ||||||||
| Address2: | STE B | ||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604621982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084604499 | ||||||||
| FaxNumber: | 7084608031 | ||||||||
| Practice Location | |||||||||
| Address1: | 2310 YORK ST | ||||||||
| Address2: | STE 2C | ||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604062411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083884903 | ||||||||
| FaxNumber: | 7083880043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036039906 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080178217 | 01 | RR MEDICARE | OTHER | 1626986 | 01 | IL | BLUE SHIELD | OTHER | 036039906 | 05 | IL | MEDICAID |