Provider Demographics
NPI:1043653082
Name:CRESTON MEDICAL SERVICE, PC
Entity Type:Organization
Organization Name:CRESTON MEDICAL SERVICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:BEARDSLEE
Authorized Official - Last Name:APP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-776-1275
Mailing Address - Street 1:PO BOX 264
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-0264
Mailing Address - Country:US
Mailing Address - Phone:616-776-1275
Mailing Address - Fax:
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:49505-5091
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:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301029675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB47425Medicare UPIN