Provider Demographics
NPI:1073584686
Name:PROMMERSBERGER, JAMES EDWIN (DPM)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWIN
Last Name:PROMMERSBERGER
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 1:940 WINDHAM CT
Mailing Address - Street 2:SUITE #3
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5060
Mailing Address - Country:US
Mailing Address - Phone:330-726-3348
Mailing Address - Fax:330-726-3856
Practice Address - Street 1:940 WINDHAM CT
Practice Address - Street 2:SUITE #3
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5060
Practice Address - Country:US
Practice Address - Phone:330-726-3348
Practice Address - Fax:330-726-3856
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2619213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0774194Medicaid
OH000000177949OtherANTHEM
OHP00199462OtherMEDICARE TRAVELERS
WV000601363OtherBLUE SHIELD MOUNTAIN STATE
WV0099572000OtherMEDICAID WV
WV0655751Medicare PIN
OH0774194Medicaid
OHPR0655752Medicare ID - Type Unspecified