1588850234 NPI number — CEDAR VALLEY MEDICAL SPECIALISTS, PC

Table of content: (NPI 1588850234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588850234 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:
CEDAR VALLEY PAIN CLINIC
Provider Other Organization Name Type Code:
3
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:
1588850234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2008
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:
319-235-5390
Provider Business Mailing Address Fax Number:
319-235-5607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3254 KIMBALL 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:
50702-5739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-235-7246
Provider Business Practice Location Address Fax Number:
319-235-3017
Provider Enumeration Date:
09/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
IREY
Authorized Official First Name:
GILMORE
Authorized Official Middle Name:
J.
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)





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