Basic Information
| Provider Information | |||||||||
| NPI: | 1275589251 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDAR VALLEY MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634023 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138912813 | ||||||||
| FaxNumber: | 5137931032 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 N CROSS ST | ||||||||
| Address2: | |||||||||
| City: | WEST UNION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456931209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375448989 | ||||||||
| FaxNumber: | 9375445659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | SHUPERT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9375448989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65942609 | 05 | KY | MEDICAID | DC2504 | 01 | OH | RAILROAD MEDICARE | OTHER | 2445232 | 05 | OH | MEDICAID |