MEDICARE: IVYREHAB DELAWARE LLC

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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1750927141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVYREHAB DELAWARE LLC

Provider Business Mailing Address
First Line	:	1311 MAMARONECK AVE STE 140
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10605-5224
Country	:	US
Telephone Number	:	914-294-4050
Fax Number	:

Provider Business Practice Location Address
First Line	:	2710 PHILADELPHIA PIKE STE E
Second Line	:
City	:	CLAYMONT
State	:	DE
Zip	:	19703-2568
Country	:	US
Telephone Number	:	631-580-5200
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL RUCKER
Credential	:
Telephone Number	:	631-580-5200

Provider Enumeration Date	:	11/21/2019
Last Update Date	:	08/12/2022

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