Provider Demographics
NPI:1285643825
Name:BOCK, JAMES MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:BOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:113 E SEIBERLING ST
Mailing Address - Street 2:
Mailing Address - City:BLUE MOUND
Mailing Address - State:IL
Mailing Address - Zip Code:62513-0260
Mailing Address - Country:US
Mailing Address - Phone:217-692-2151
Mailing Address - Fax:217-692-2121
Practice Address - Street 1:4965 E LOST BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5139
Practice Address - Country:US
Practice Address - Phone:217-864-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-077533Medicaid
IL036-077533OtherSTATE LICENSE
BB1601031OtherDEA - CONTROLLED SUBSTANC
ILE35534Medicare UPIN