Provider Demographics
NPI:1154583078
Name:CRESTON MEDICAL CENTER, PLLC
Entity type:Organization
Organization Name:CRESTON MEDICAL CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGO
Authorized Official - Middle Name:MARYLAND
Authorized Official - Last Name:APP
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:616-776-0814
Mailing Address - Street 1:PO BOX 2564
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-2564
Mailing Address - Country:US
Mailing Address - Phone:616-776-1275
Mailing Address - Fax:616-776-3713
Practice Address - Street 1:1330 PLAINFIELD AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4913
Practice Address - Country:US
Practice Address - Phone:616-776-1275
Practice Address - Fax:616-776-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029675261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN662300Medicare PIN