Provider Demographics
NPI:1861428732
Name:PHOTIADIS, JAMES (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:PHOTIADIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4243 SUN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-9255
Mailing Address - Country:US
Mailing Address - Phone:812-949-5214
Mailing Address - Fax:
Practice Address - Street 1:2015 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4337
Practice Address - Country:US
Practice Address - Phone:812-649-2511
Practice Address - Fax:812-649-7867
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35451207L00000X, 207Q00000X
IN01061798A207P00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000664846OtherANTHEM - NICC
KY7100063510Medicaid
KY115372OtherSIHO - NICC
IN200192420Medicaid
KY7100063510Medicaid
TN621505831OtherGROUP TAX ID NUMBER
KYP400016370Medicare PIN