Provider Demographics
NPI:1609949304
Name:DIMAILIG, JAMES HARDEY (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:HARDEY
Last Name:DIMAILIG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:3229 BROADWAY STE 112
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1040
Practice Address - Country:US
Practice Address - Phone:219-980-0167
Practice Address - Fax:219-980-0198
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009135A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000504588OtherANTHEM - MBWOUDE
IN000000504597OtherANTHEM - APT PLUS
IN000000504592OtherANTHEM - 1ST AID PLUS
IN000000504588OtherANTHEM - MBWOUDE
IN000000504592OtherANTHEM - 1ST AID PLUS
IN214680VMedicare ID - Type UnspecifiedPART B GROUP MEMBER