Provider Demographics
NPI:1821091810
Name:DELINE, JAMES L (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:DELINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:L
Other - Last Name:DELINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:307 MCKAY ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-2029
Mailing Address - Country:US
Mailing Address - Phone:660-385-3141
Mailing Address - Fax:660-385-5866
Practice Address - Street 1:307 MCKAY ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2029
Practice Address - Country:US
Practice Address - Phone:660-385-3141
Practice Address - Fax:660-385-5866
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD 36425207Q00000X
MO36425207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
54535OtherUNITED HEALTHCARE
MO11794OtherBLUE CROSS
193025OtherTHE FUNDS
MO431671124DELOtherMERCY HEALTH PLANS
IA1930156Medicaid
930078535OtherRAILROAD MEDICARE
010012805OtherRAILROAD MEDICARE
252291OtherHEALTHLINK HMO AND PPO
MO202144804Medicaid
MO095075236Medicare PIN
54535OtherUNITED HEALTHCARE
010012805OtherRAILROAD MEDICARE
930078535OtherRAILROAD MEDICARE