Basic Information
| Provider Information | |||||||||
| NPI: | 1700239332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAMES | ||||||||
| FirstName: | TIPHANI | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIMES | ||||||||
| OtherFirstName: | TIPHANI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5092 HERMITAGE TRL | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611147088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062884816 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1253 N ALPINE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611072201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796969201 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2016 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 135.000930 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 016-005842 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.