Basic Information
Provider Information | |||||||||
NPI: | 1124646617 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IVYREHAB NETWORK, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1311 MAMARONECK AVE STE 140 | ||||||||
Address2: |   | ||||||||
City: | WHITE PLAINS | ||||||||
State: | NY | ||||||||
PostalCode: | 106055224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9142944050 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 109 ROUTE 46 | ||||||||
Address2: |   | ||||||||
City: | DENVILLE | ||||||||
State: | NJ | ||||||||
PostalCode: | 078342776 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9736250733 | ||||||||
FaxNumber: | 9736250741 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2020 | ||||||||
LastUpdateDate: | 08/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUCKER | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6315805200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.