Provider Demographics
NPI:1891803110
Name:MACEK, JAMES MICHAEL (DPM)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:MACEK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 E FERRIS ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-4810
Mailing Address - Country:US
Mailing Address - Phone:309-343-6212
Mailing Address - Fax:309-343-6164
Practice Address - Street 1:347 E FERRIS ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-4810
Practice Address - Country:US
Practice Address - Phone:309-343-6212
Practice Address - Fax:309-343-6164
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003711213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T38196Medicare UPIN
IL736230Medicare ID - Type Unspecified
IL0599950001Medicare NSC