Healthcare Provider Details

I. General information

NPI: 1689653792
Provider Name (Legal Business Name): JON I MCIVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 PHALEN BLVD
SAINT PAUL MN
55130-2400
US

IV. Provider business mailing address

10016 INDIGO DR
EDEN PRAIRIE MN
55347-1206
US

V. Phone/Fax

Practice location:
  • Phone: 651-495-6600
  • Fax: 952-883-9677
Mailing address:
  • Phone: 612-751-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number42697
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: