Basic Information
Provider Information | |||||||||
NPI: | 1942650700 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ST. CLAIR | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | BENJAMIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8558 BROADWAY | ||||||||
Address2: |   | ||||||||
City: | MERRILLVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 464107032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2193927084 | ||||||||
FaxNumber: | 2197039685 | ||||||||
Practice Location | |||||||||
Address1: | 1500 S LAKE PARK AVE | ||||||||
Address2: | SP402 | ||||||||
City: | HOBART | ||||||||
State: | IN | ||||||||
PostalCode: | 463426638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2199476009 | ||||||||
FaxNumber: | 2199476015 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2016 | ||||||||
LastUpdateDate: | 07/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 286571 | MA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | 01088114A | IN | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
ID | Type | State | Issuer | Description | 300064568 | 05 | IN |   | MEDICAID |