Basic Information
Provider Information | |||||||||
NPI: | 1619085354 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VINCENT M IVERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8401 TRADEWINDS DR | ||||||||
Address2: |   | ||||||||
City: | PORT ST JOE | ||||||||
State: | FL | ||||||||
PostalCode: | 324566157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504781312 | ||||||||
FaxNumber: | 8504749060 | ||||||||
Practice Location | |||||||||
Address1: | 301 20TH ST | ||||||||
Address2: |   | ||||||||
City: | PORT ST JOE | ||||||||
State: | FL | ||||||||
PostalCode: | 324563301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502277070 | ||||||||
FaxNumber: | 8502271989 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2006 | ||||||||
LastUpdateDate: | 06/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IVERS | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8502277070 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME65165 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 26155 | 01 | FL | BCBS OF FLORIDA | OTHER | 376567900 | 05 | FL |   | MEDICAID |