Provider Demographics
NPI:1790774594
Name:COUNTRYMAN, JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:COUNTRYMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:COUNTRYMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:2512 ELM ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2307
Mailing Address - Country:US
Mailing Address - Phone:563-359-6907
Mailing Address - Fax:
Practice Address - Street 1:1000 BRADY ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-5214
Practice Address - Country:US
Practice Address - Phone:563-884-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05113111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA24031OtherBLUE CROSS BLUE SHIELD
IA0748137Medicaid
IAI1480Medicare ID - Type Unspecified
IA0748137Medicaid