Provider Demographics
NPI:1780658815
Name:RUPP, JAMES JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:RUPP
Suffix:JR
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 1:2160 S FIRST AVE
Mailing Address - Street 2:(321 N. LAGRANGE RD., LAGRANGE PRK, IL. 60526)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-485-1020
Mailing Address - Fax:708-485-1173
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(321 N. LAGRANGE RD., LAGRANGE PRK, IL. 60526)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-485-1020
Practice Address - Fax:708-485-1173
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36106896207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21172OtherMEDICARE
IL36106896Medicaid
IL203456Medicare ID - Type Unspecified
IL36106896Medicaid