Basic Information
| Provider Information | |||||||||
| NPI: | 1821042318 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDAR VALLEY MEDICAL SPECIALISTS PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST UNION DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2758 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507042758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634225734 | ||||||||
| FaxNumber: | 5634225830 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 HIGHWAY 150 N | ||||||||
| Address2: | |||||||||
| City: | WEST UNION | ||||||||
| State: | IA | ||||||||
| PostalCode: | 521751003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634225734 | ||||||||
| FaxNumber: | 5634225830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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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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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 62526 | 01 | IA | WELLMARK | OTHER | 0625269 | 05 | IA | MEDICAID |