Provider Demographics
NPI:1962457622
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: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:319-833-5907
Mailing Address - Fax:319-833-5908
Practice Address - Street 1:1753 W RIDGEWAY AVE
Practice Address - Street 2:STE 107
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4588
Practice Address - Country:US
Practice Address - Phone:319-833-5907
Practice Address - Fax:319-833-5908
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
IA0285171Medicaid
IA0952750002Medicare NSC