Provider Demographics
NPI:1053423020
Name:MULVANEY, JAMES M
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:MULVANEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 LINCOLNSHIRE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2157
Mailing Address - Country:US
Mailing Address - Phone:618-242-2317
Mailing Address - Fax:618-242-9710
Practice Address - Street 1:1007 S 42ND ST
Practice Address - Street 2:SUITE 5
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6217
Practice Address - Country:US
Practice Address - Phone:618-244-1163
Practice Address - Fax:618-244-1522
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700009894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0004132022OtherBLUESHIELD
0004132022OtherBLUESHIELD