Provider Demographics
NPI:1487783510
Name:TAVELLI, JAMES ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ANTHONY
Last Name:TAVELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:5211 COMMERCE CROSSINGS DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-2183
Practice Address - Country:US
Practice Address - Phone:502-966-3918
Practice Address - Fax:502-969-3665
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR1109208000000X
KY41964208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100272550Medicaid
KY000000845603OtherANTHEM-NCMA
KY131041OtherSIHO-NCMA
IN201221770Medicaid
KYK097431OtherMEDICARE
KY50061769OtherPASSPORT-NCMA