Basic Information
| Provider Information | |||||||||
| NPI: | 1831194828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAFOLLETTE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 LANDMARK AVE. | ||||||||
| Address2: | PO BOX 550 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474020550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123329496 | ||||||||
| FaxNumber: | 8123395229 | ||||||||
| Practice Location | |||||||||
| Address1: | 2605 E. CREEK'S EDGE DR. | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123329496 | ||||||||
| FaxNumber: | 8123395229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
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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 | 207Q00000X | 01021192A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100182460 | 05 | IN | MEDICAID |