Healthcare Provider Details

I. General information

NPI: 1568459212
Provider Name (Legal Business Name): ERNEST RACKLEY IVEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: E RACKLEY IVEY M.D.

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4346 LAKESHORE LN UNIT 304
CHATTANOOGA TN
37415-7169
US

IV. Provider business mailing address

1300 SOUTH DRIVE
WINNEBAGO WI
54985-0009
US

V. Phone/Fax

Practice location:
  • Phone: 608-354-3947
  • Fax:
Mailing address:
  • Phone: 920-235-4910
  • Fax: 920-237-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number44317-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number44317-020
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number44317-020
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number44317-020
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number0101232074
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number44317-020
License Number StateWI
# 7
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number44317-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: