Basic Information
| Provider Information | |||||||||
| NPI: | 1750336491 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDAR VALLEY MEDICAL SPECIALISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2758 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507042758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198335922 | ||||||||
| FaxNumber: | 3198335923 | ||||||||
| Practice Location | |||||||||
| Address1: | 4612 PRAIRIE PKWY | ||||||||
| Address2: | |||||||||
| City: | CEDAR FALLS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506137971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194727222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | IREY | ||||||||
| AuthorizedOfficialFirstName: | GILMORE | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3192355390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CEDAR VALLEY MEDICAL SPECIALISTS PC | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 0285148 | 05 | IA | MEDICAID |