Basic Information
Provider Information | |||||||||
NPI: | 1568439321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IVEY | ||||||||
FirstName: | TOM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4380 MALSBARY RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452425644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5133664488 | ||||||||
FaxNumber: | 5133664480 | ||||||||
Practice Location | |||||||||
Address1: | 2123 AUBURN AVE | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452192906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5136511180 | ||||||||
FaxNumber: | 5136512175 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2006 | ||||||||
LastUpdateDate: | 12/20/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35057125 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 311438871035 | 01 |   | CARESOURCE | OTHER | 0706696 | 05 | OH |   | MEDICAID | 285277 | 01 |   | AMERIGROUP | OTHER | 000000218059 | 01 |   | ANTHEM | OTHER | 64860414 | 05 | KY |   | MEDICAID | 1800392 | 01 |   | UHNITED | OTHER | 5712508 | 01 |   | HUMANA CHOICECARE | OTHER | 2685094 | 01 |   | AETNA | OTHER |