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General NPI Number Information
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NPI Number | 1073818787
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Entity Type | Organization
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Legal Business Name | IVY FAMILY MEDICINE, PLC
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Dates
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Enumeration Date | 01/12/2011
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Last Update Date | 04/18/2011
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Provider Practice Location Address
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Address Line | 2 BOARS HEAD PL SUITE 110
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22903-4611
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Country | US
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Telephone | 434-466-8363
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Fax |
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Provider Business Mailing Address
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Address Line | 516 ROOKWOOD PL
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22903-4734
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Country | US
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Telephone | 434-466-8363
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LILY WISE HARGROVE
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Credential | MD
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Telephone | 434-466-8363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 0101057199
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License Number State | VA
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