Healthcare Provider Details

I. General information

NPI: 1821091810
Provider Name (Legal Business Name): JAMES L DELINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JIM L DELINE M.D.

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 MCKAY ST
MACON MO
63552-2029
US

IV. Provider business mailing address

307 MCKAY ST
MACON MO
63552-2029
US

V. Phone/Fax

Practice location:
  • Phone: 660-385-3141
  • Fax: 660-385-5866
Mailing address:
  • Phone: 660-385-3141
  • Fax: 660-385-5866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD 36425
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number36425
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: