Provider Demographics
NPI: | 1780042366 |
---|---|
Name: | CEDAR VALLEY MEDICAL SPECIALISTS, PC |
Entity Type: | Organization |
Organization Name: | CEDAR VALLEY MEDICAL SPECIALISTS, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | GILMORE |
Authorized Official - Middle Name: | |
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: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4006 JOHNATHAN ST |
Practice Address - Street 2: | STE B |
Practice Address - City: | WATERLOO |
Practice Address - State: | IA |
Practice Address - Zip Code: | 50701-9395 |
Practice Address - Country: | US |
Practice Address - Phone: | 319-233-0222 |
Practice Address - Fax: | 319-287-8094 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-02-10 |
Last Update Date: | 2016-02-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IA | 1497794242 | Medicaid | |
IA | 1497794242 | Medicaid |