MEDICARE: DR. IAN MARTIN SHIVACK M.D.

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	2084P0800X	Psychiatry Physician	24360	AZ

General Provider Information

NPI Number	:	1891139994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IAN MARTIN SHIVACK M.D.

Provider Business Mailing Address
First Line	:	4250 N CAMINO ARCO
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-7015
Country	:	US
Telephone Number	:	520-529-3940
Fax Number	:	520-529-3940

Provider Business Practice Location Address
First Line	:	4250 N CAMINO ARCO
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-7015
Country	:	US
Telephone Number	:	520-529-3940
Fax Number	:	520-529-3940

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

Provider Enumeration Date	:	04/19/2013
Last Update Date	:	04/19/2013

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