MEDICARE: DR. TIMOTHY R IVEY M.D.

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	207R00000X	Internal Medicine Physician	13532	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902802333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY R IVEY M.D.

Provider Business Mailing Address
First Line	:	11700 HIGHWAY 57
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565-8309
Country	:	US
Telephone Number	:	228-826-1482
Fax Number	:	228-826-5924

Provider Business Practice Location Address
First Line	:	11700 HIGHWAY 57
Second Line	:
City	:	VANCLEAVE
State	:	MS
Zip	:	39565-8309
Country	:	US
Telephone Number	:	228-826-1482
Fax Number	:	228-826-5924

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	12/29/2015

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