Provider Demographics
NPI:1598766966
Name:MASSIMILIAN, JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:MASSIMILIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9944 S ROBERTS RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1555
Mailing Address - Country:US
Mailing Address - Phone:708-233-8709
Mailing Address - Fax:
Practice Address - Street 1:12251 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:708-923-5800
Practice Address - Fax:708-923-8324
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079253207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079253Medicaid
ILE19275Medicare UPIN
L03576Medicare PIN