Basic Information
| Provider Information | |||||||||
| NPI: | 1003837410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVANITSKY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | MSTISLAVOVICH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COQUILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974231666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413963111 | ||||||||
| FaxNumber: | 5413968135 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COQUILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974231699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413963111 | ||||||||
| FaxNumber: | 5413968135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD22589 | OR | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 288121 | 05 | OR | MEDICAID |