Provider Demographics
NPI:1407870058
Name:CEDAR VALLEY PATHOLOGISTS PC
Entity Type:Organization
Organization Name:CEDAR VALLEY PATHOLOGISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-369-7002
Mailing Address - Street 1:PO BOX 957076
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-7076
Mailing Address - Country:US
Mailing Address - Phone:407-422-9831
Mailing Address - Fax:
Practice Address - Street 1:1026 A AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5036
Practice Address - Country:US
Practice Address - Phone:319-369-7002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0090449Medicaid
IA0090449Medicaid