Provider Demographics
NPI:1528013299
Name:CEDAR VALLEY MEDICAL SPECIALISTS PC
Entity Type:Organization
Organization Name:CEDAR VALLEY MEDICAL SPECIALISTS PC
Other - Org Name:ADVANCED DIAGNOSTIC IMAGINING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GILMORE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:IREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-235-5390
Mailing Address - Street 1:PO BOX 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-236-2700
Mailing Address - Fax:319-236-2714
Practice Address - Street 1:4006 JOHNATHAN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-9395
Practice Address - Country:US
Practice Address - Phone:319-236-2700
Practice Address - Fax:319-236-2714
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CEDAR VALLEY MEDICAL SPECIALISTS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0481648Medicaid
IA0481648Medicaid