Active NPI
James Edward Wallace Jr., PA-C
- Physician Assistant
- Champaign, IL
National Provider Identifier
1053539783
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 85000087
- Practice address
- 101 W University Ave
Spine and Pain Management
Champaign, IL 61820-3909 - Phone
- (217) 366-8796
- Fax
- (217) 366-6106
- NPI assigned
- Apr 20, 2007
- Last updated
- Sep 24, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 85000087 | IL | Primary |
Addresses
Primary practice location
101 W University Ave
Spine and Pain Management
Champaign, IL 61820-3909
Mailing address
101 W University Ave
Spine and Pain Management
Champaign, IL 61820-3909
Phone (217) 366-1326
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 85000087 | IL | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Gibson Community Hospital Association | Past | Accepting new patients | |
| Christie Clinic, PLLC | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Internal Medicine Physician
- Champaign, IL
- NPI 1871523829
-
dba Gibson Area Hospital and Health Services
- Critical Access Hospital
- Gibson City, IL
- NPI 1114935681
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1177027200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1379980800000",
"number": "1053539783",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "101 W UNIVERSITY AVE",
"address_2": "SPINE AND PAIN MANAGEMENT",
"city": "CHAMPAIGN",
"state": "IL",
"postal_code": "618203909",
"telephone_number": "217-366-1326",
"fax_number": "217-366-6106"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "101 W UNIVERSITY AVE",
"address_2": "SPINE AND PAIN MANAGEMENT",
"city": "CHAMPAIGN",
"state": "IL",
"postal_code": "618203909",
"telephone_number": "217-366-8796",
"fax_number": "217-366-6106"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "JAMES",
"middle_name": "EDWARD",
"name_prefix": "Mr.",
"name_suffix": "Jr.",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-04-20",
"last_updated": "2013-09-24",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "IL",
"license": "85000087",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Champaign, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 24, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.