Provider Demographics
NPI:1558341628
Name:MCKERNAN, GREGORY C (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:MCKERNAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1355 50TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1617
Mailing Address - Country:US
Mailing Address - Phone:515-225-3261
Mailing Address - Fax:515-225-1944
Practice Address - Street 1:1355 50TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1617
Practice Address - Country:US
Practice Address - Phone:515-225-3261
Practice Address - Fax:515-225-1944
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IADO-02827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA38887OtherBCBS
IA5105601Medicaid
IA38969OtherBCBS
IA4105601Medicaid
IAP00246380OtherTRAVELERS MEDICARE
IAI15471Medicare ID - Type Unspecified
IA38969OtherBCBS
IAE86639Medicare UPIN