MEDICARE: DR. SUSAN LEE IVEY MD

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	207Q00000X	Family Medicine Physician	C43335	CA

General Provider Information

NPI Number	:	1003004169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN LEE IVEY MD

Provider Business Mailing Address
First Line	:	131 EMERALD DR
Second Line	:
City	:	DANVILLE
State	:	CA
Zip	:	94526-2426
Country	:	US
Telephone Number	:	925-362-8227
Fax Number	:	925-362-8228

Provider Business Practice Location Address
First Line	:	2140 SHATTUCK AVE
Second Line	:	10TH FLOOR, HEALTH RESEARCH FOR ACTION, UC-BERKELEY SPH
City	:	BERKELEY
State	:	CA
Zip	:	94704-1210
Country	:	US
Telephone Number	:	510-643-1883
Fax Number	:	510-643-7976

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

Provider Enumeration Date	:	10/12/2007
Last Update Date	:	10/12/2007

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