MEDICARE: AMANDA MICHELLE IVY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	N9880	TX

General Provider Information

NPI Number	:	1518055508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MICHELLE IVY MD

Provider Business Mailing Address
First Line	:	1340 WONDER WORLD DR
Second Line	:	STE 4301
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-7598
Country	:	US
Telephone Number	:	512-353-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 WONDER WORLD DR
Second Line	:	STE 4301
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-7598
Country	:	US
Telephone Number	:	512-353-6400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	09/22/2011

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