Basic Information
| Provider Information | |||||||||
| NPI: | 1730100405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ESTILL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179623834 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7950 W JEFFERSON BLVD | ||||||||
| Address2: | SUITE 2121 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604078000 | ||||||||
| FaxNumber: | 2604078004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02001319A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 02001319 | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100369370 | 05 | IN | MEDICAID |