Provider Demographics
NPI:1316991607
Name:CRESTON MEDICAL CLINIC, P.C.
Entity type:Organization
Organization Name:CRESTON MEDICAL CLINIC, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF THE CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-782-2131
Mailing Address - Street 1:1610 W TOWNLINE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-1066
Mailing Address - Country:US
Mailing Address - Phone:641-782-2131
Mailing Address - Fax:641-782-6425
Practice Address - Street 1:1610 W TOWNLINE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1066
Practice Address - Country:US
Practice Address - Phone:641-782-2131
Practice Address - Fax:641-782-6425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0265793Medicaid
IA26579OtherWELLMARK BCBS CRNA #
26579Medicare ID - Type UnspecifiedMEDICARE CRNA BILLING #