=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821401589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES HALPIN MA, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2014
-----------------------------------------------------
Last Update Date | 12/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1402 S 1ST ST
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-6916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-244-6884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 E SOUTH MAHOMET RD
-----------------------------------------------------
City | MAHOMET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61853-3613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-441-0621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096.002244
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------