Basic Information
| Provider Information | |||||||||
| NPI: | 1417955246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ONEILL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 BOW POINTE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483463198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486252621 | ||||||||
| FaxNumber: | 2486258938 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 BOW POINTE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483463198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486252621 | ||||||||
| FaxNumber: | 2486258938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | JO023587 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | P00907581 | 01 | MI | RAILROAD MEDICARE IND PIN | OTHER | 3506366411 | 01 | MI | BCBS IND | OTHER | 1417955246 | 05 | MI | MEDICAID | 1667230 | 05 | MI | MEDICAID |