Healthcare Provider Details

I. General information

NPI: 1063439503
Provider Name (Legal Business Name): JAMES ELLIS D.O., FACEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N MAPLE ST
EFFINGHAM IL
62401-2006
US

IV. Provider business mailing address

75 REMIT DRIVE LOCKBOX 6065
CHICAGO IL
60675-6065
US

V. Phone/Fax

Practice location:
  • Phone: 217-337-2000
  • Fax:
Mailing address:
  • Phone: 866-916-5259
  • Fax: 231-922-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-099455
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH46397
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH6194
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO20976
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO25267
License Number StateDC
# 6
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101018060
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4011
License Number StateIA
# 8
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0533706
License Number StateKS
# 9
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.009604
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: