Healthcare Provider Details

I. General information

NPI: 1598741050
Provider Name (Legal Business Name): THEODORE G JAMES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 YORK ST STE 2C
BLUE ISLAND IL
60406-2411
US

IV. Provider business mailing address

10660 W 143RD ST STE B
ORLAND PARK IL
60462-1982
US

V. Phone/Fax

Practice location:
  • Phone: 708-388-4903
  • Fax: 708-388-0043
Mailing address:
  • Phone: 708-460-4499
  • Fax: 708-460-8031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036039906
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: