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Organization
JAMES R DEBORD
Active
Organization
JAMES R DEBORD
Active
Other names
Vascular Laboratory Services
Organization subpart
No
Provider details
NPI number
Authorized official
JAMES DEBORD M.D. (PRESIDENT)
(877) 852-4669
Entity
Organization
Contact information
Practice address
5409 N KNOXVILLE AVE, PEORIA, IL 61614-5016
(877) 852-4669
Mailing address
PO BOX 10140, PEORIA, IL 61612-0140
(877) 852-4669
Taxonomy
Speciality
Code
Description
License number
State
2086S0129X
Vascular Surgery Physician
Primary
—
NULL
2086S0129X
Vascular Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0360520633
—
IL
01
—
07200604
BLUE CROSS BLUE SHIELD
IL
01
—
330001311
RAILROAD MEDICARE
IL
Enumeration date
08/03/2006
Last updated
06/01/2011
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