Basic Information
| Provider Information | |||||||||
| NPI: | 1609818657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MESEROW | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D., F.A.C.O.G. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 PLEASANT STREET | ||||||||
| Address2: | SOUTH 2 ROOM 236 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152416228 | ||||||||
| FaxNumber: | 5152418685 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 30TH AVE S STE 102 | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582016009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8775221275 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | 61-4418 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207VM0101X | MC-0085 | ID | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 036-059865 | IL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | MD-45006 | IA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-059865 | 05 | IL | MEDICAID | 1609818657 | 05 | IA | MEDICAID |