Provider Demographics
NPI:1063439503
Name:ELLIS, JAMES (DO, FACEP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO, FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 REMIT DRIVE
Mailing Address - Street 2:LOCKBOX 6065
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6065
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:503 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2006
Practice Address - Country:US
Practice Address - Phone:217-337-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-099455207P00000X
MDH46397207P00000X
TXH6194207P00000X
DCDO20976207P00000X
DCDO25267207P00000X
MI5101018060207P00000X
IA4011207P00000X
KS0533706207P00000X
OH34.009604207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063439503Medicaid
MT1063439503Medicaid
MI5261624OtherBCBS
IL0036099455Medicaid
KS200604190BMedicaid
IL036099455-4Medicaid
IL036099455-5Medicaid
IL036099455-8Medicaid
IA1063439503Medicaid
ID1063439503Medicaid
OHEL4268421Medicaid
KS1063439503OtherBLUE SHIELD
MI1063439503Medicaid
NE1063439503Medicaid
OH2966778Medicaid
IL036099455-7Medicaid
IL036099455-9Medicaid
IL036099455Medicaid
IA1063439503OtherBLUE SHIELD
WA1063439503Medicaid
MI5261624OtherBCBS
IL036099455-8Medicaid
ILK02725Medicare PIN
IL036099455-4Medicaid
NE1063439503Medicaid
ILK02717Medicare PIN
NENA1613003Medicare PIN
WAG8890942Medicare PIN
KS200604190BMedicaid
MI1063439503Medicaid
MO1063439503Medicaid
OHEL4268421Medicaid
MIP29950025Medicare PIN
MO147480019Medicare PIN
ILIL1943007Medicare PIN
IL207236007Medicare PIN
F20901Medicare UPIN
WA1063439503Medicaid
KSKA1000022Medicare PIN
MIMI1609018Medicare PIN
OHP00743562Medicare PIN
MO150050015Medicare PIN