Provider Demographics
NPI:1700922267
Name:PHOENIX, JAMES W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:PHOENIX
Suffix:
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 1:1747 HENRY LUCKOW LN
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-1702
Mailing Address - Country:US
Mailing Address - Phone:815-971-3030
Mailing Address - Fax:815-971-9895
Practice Address - Street 1:1747 HENRY LUCKOW LN
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1702
Practice Address - Country:US
Practice Address - Phone:815-971-3030
Practice Address - Fax:815-971-9895
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400205679OtherMEDICARE PTAN
IL036059274Medicaid
IL036059274Medicaid
C45417Medicare UPIN