Provider Demographics
NPI:1992762173
Name:ERTLE, JAMES OWEN (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:OWEN
Last Name:ERTLE
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 1:333 CHESTNUT ST
Mailing Address - Street 2:STE 202
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 CHESTNUT ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3247
Practice Address - Country:US
Practice Address - Phone:630-325-6880
Practice Address - Fax:630-325-5975
Is Sole Proprietor?:No
Enumeration Date:2006-04-30
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036043180207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1992762173OtherNPI
IL036043180Medicaid
IL313480OtherMEDICARE ID/TYPE UNSPECIF
IL0002215658OtherBCBSIL
ILIL2485004Medicare PIN
IL313480OtherMEDICARE ID/TYPE UNSPECIF
ILC39542Medicare UPIN