Provider Demographics
NPI:1942545975
Name:NORTHERN IOWA CARDIOVASCULAR AND THORACIC SURGERY CLINIC, PC
Entity Type:Organization
Organization Name:NORTHERN IOWA CARDIOVASCULAR AND THORACIC SURGERY CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EROMOSELE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:OTOADESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-233-3044
Mailing Address - Street 1:PO BOX 2660
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2660
Mailing Address - Country:US
Mailing Address - Phone:319-233-3044
Mailing Address - Fax:319-233-0722
Practice Address - Street 1:1753 W RIDGEWAY AVE STE 111
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4588
Practice Address - Country:US
Practice Address - Phone:319-233-6211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28663208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty