Provider Demographics
NPI:1558352443
Name:MCILWAINE, JAMES W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:MCILWAINE
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 1:901 PATIENTS FIRST DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-390-1570
Mailing Address - Fax:636-390-1571
Practice Address - Street 1:901 PATIENTS FIRST DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4700
Practice Address - Country:US
Practice Address - Phone:636-390-1570
Practice Address - Fax:636-390-1571
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002002082207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204576300Medicaid
P00445875OtherRAILROOAD MEDICARE
932752943Medicare Oscar/Certification
932752943Medicare PIN
MO204576300Medicaid