Provider Demographics
NPI:1740279157
Name:MCCONVILLE, JAMES BRAD (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:BRAD
Last Name:MCCONVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:MCCONVILLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19876 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-8850
Mailing Address - Country:US
Mailing Address - Phone:641-856-8684
Mailing Address - Fax:641-856-3009
Practice Address - Street 1:19876 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-8850
Practice Address - Country:US
Practice Address - Phone:641-856-8684
Practice Address - Fax:641-856-3009
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3127381Medicaid
IAP00000614OtherRR MEDICARE
A01112Medicare UPIN
IA3127381Medicaid