1255385928 NPI number — CEDAR VALLEY MEDICAL SPECIALISTS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255385928 NPI number — CEDAR VALLEY MEDICAL SPECIALISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR VALLEY MEDICAL SPECIALISTS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255385928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2758
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50704-2758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-833-5900
Provider Business Mailing Address Fax Number:
319-833-5901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1731 W RIDGEWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50701-4591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-833-5900
Provider Business Practice Location Address Fax Number:
319-833-5901
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IREY
Authorized Official First Name:
GILMORE
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
319-235-5390

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0283291 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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