Provider Demographics
NPI:1891885281
Name:WERTHEIMER, JAMES L (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:WERTHEIMER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 BLUE STAR HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-7758
Mailing Address - Country:US
Mailing Address - Phone:269-637-1115
Mailing Address - Fax:269-639-1314
Practice Address - Street 1:930 BLUE STAR HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7758
Practice Address - Country:US
Practice Address - Phone:269-637-1115
Practice Address - Fax:269-639-1314
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC1124363A00000X
MI5601006282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ73242Medicare UPIN
SC3921Medicare PIN
SCAA16043921Medicare PIN