Provider Demographics
NPI:1386610376
Name:KETCHUM, JAMES W (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15945 CLAYTON RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2490
Mailing Address - Country:US
Mailing Address - Phone:636-256-5350
Mailing Address - Fax:636-256-5372
Practice Address - Street 1:15945 CLAYTON RD
Practice Address - Street 2:SUITE 310
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2490
Practice Address - Country:US
Practice Address - Phone:636-256-5350
Practice Address - Fax:636-256-5372
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8D28207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10417Medicare UPIN