Provider Demographics
NPI:1740232842
Name:CRESTON MEDICAL CLINIC, P.C.
Entity Type:Organization
Organization Name:CRESTON MEDICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF THE CORPORATION
Authorized Official - Prefix:DR
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:2006-05-17
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01353OtherWELLMARK BCBS GROUP #
IAC54555OtherRAILROAD GROUP BILLING #
IA01353OtherWELLMARK BCBS #
IA0013532Medicaid
IA01353OtherWELLMARK BCBS #