Healthcare Provider Details

I. General information

NPI: 1447234521
Provider Name (Legal Business Name): MARY E IVY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 09/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 W 2ND AVE
LITITZ PA
17543-1816
US

IV. Provider business mailing address

562 W 2ND AVE
LITITZ PA
17543-1816
US

V. Phone/Fax

Practice location:
  • Phone: 717-626-2167
  • Fax: 717-626-1915
Mailing address:
  • Phone: 717-626-2167
  • Fax: 717-626-1915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD040279L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5171073
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA NON-HMO
# 2
Identifier578399
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA HMO
# 3
IdentifierD71478
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHEALTH ASSURANCE
# 4
IdentifierP002302
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGATEWAY HEALTH PLAN
# 5
Identifier52447 S1QG
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER HEALTH PLAN
# 6
Identifier512264
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD
# 7
Identifier0011155040001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 8
Identifier01882901
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: