Healthcare Provider Details

I. General information

NPI: 1396742466
Provider Name (Legal Business Name): JAMES T NIEMEYER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E MAPLE ST
NEW LENOX IL
60451-1871
US

IV. Provider business mailing address

PO BOX 1184
BEDFORD PARK IL
60499-1184
US

V. Phone/Fax

Practice location:
  • Phone: 815-485-0760
  • Fax: 815-463-6138
Mailing address:
  • Phone: 815-485-0760
  • Fax: 815-463-6138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036084801
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: