=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851553903
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES ALVIN ENDERLE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2008
-----------------------------------------------------
Last Update Date | 05/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 W. PARK STREET
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61801-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-383-3313
-----------------------------------------------------
Fax | 217-383-4014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 W. PARK. ST.
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61801-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-383-6941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 4301092898
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------