Basic Information
| Provider Information | |||||||||
| NPI: | 1497734446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUSTER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | 1230 E. MAIN STREET | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1230 E MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC AT MAIN STREET | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 08/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 18142 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300049064 | 01 | RR MEDICARE | OTHER | 90910 | 01 | IA | BCBS | OTHER | 3M374CU | 01 | MN | BCBS | OTHER | 410849339 56001 C025 | 01 | CHAMPUS | OTHER | 928747 | 01 | IA | MEDICAID | OTHER | 232272200 | 05 | MN | MEDICAID | 764330 | 01 | MN | AMERICAS PPO | OTHER | 1600689 | 01 | MN | MEDICA | OTHER | NA2951014708 | 01 | MN | PREFERRED ONE | OTHER | 115336 | 01 | MN | UCARE | OTHER | HP24199 | 01 | MN | HEALTH PARTNERS | OTHER |