Provider Demographics
NPI:1396742466
Name:NIEMEYER, JAMES T (DO)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:NIEMEYER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1184
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-1184
Mailing Address - Country:US
Mailing Address - Phone:815-485-0760
Mailing Address - Fax:815-463-6138
Practice Address - Street 1:250 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1871
Practice Address - Country:US
Practice Address - Phone:815-485-0760
Practice Address - Fax:815-463-6138
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084801207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084801Medicaid
IL036084801Medicaid
ILP00063022Medicare PIN
IL217169001Medicare PIN
ILK01324Medicare PIN
ILF58388Medicare UPIN