Basic Information
| Provider Information | |||||||||
| NPI: | 1740279157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONVILLE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | BRAD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCONVILLE | ||||||||
| OtherFirstName: | BRAD | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19876 SAINT JOSEPH DR | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525448850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418568684 | ||||||||
| FaxNumber: | 6418563009 | ||||||||
| Practice Location | |||||||||
| Address1: | 19876 SAINT JOSEPH DR | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525448850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418568684 | ||||||||
| FaxNumber: | 6418563009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 04/23/2008 | ||||||||
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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 | 207Q00000X | 19494 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3127381 | 05 | IA | MEDICAID | P00000614 | 01 | IA | RR MEDICARE | OTHER |