MEDICARE: DR. ROBERT H IVERSEN D.C., C.C.S.P

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	111N00000X	Chiropractor	4858	AZ
2	111NS0005X	Sports Physician Chiropractor	4858	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0242900	OTHER	AZ	BCBS
2	AW2551	OTHER	AZ	HEALTHNET
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	2455228	OTHER	AZ	AETNA

General Provider Information

NPI Number	:	1114017290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT H IVERSEN D.C., C.C.S.P

Provider Business Mailing Address
First Line	:	1651 OLD MEADOW RD
Second Line	:	STE 600
City	:	MC LEAN
State	:	VA
Zip	:	22102-4311
Country	:	US
Telephone Number	:	703-506-0213
Fax Number	:

Provider Business Practice Location Address
First Line	:	2702 N 44TH ST
Second Line	:	101A
City	:	PHOENIX
State	:	AZ
Zip	:	85008-1583
Country	:	US
Telephone Number	:	480-990-9095
Fax Number	:	480-941-1233

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	02/01/2010

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