MEDICARE: DR. IVY FASKE 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	208000000X	Pediatrics Physician	ME 49705	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04337	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1942201868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVY FASKE M.D.

Provider Business Mailing Address
First Line	:	11211 PROSPERITY FARMS RD STE A102
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-3479
Country	:	US
Telephone Number	:	561-626-4677
Fax Number	:	561-293-7060

Provider Business Practice Location Address
First Line	:	3365 BURNS RD
Second Line	:	SUITE 206
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-4303
Country	:	US
Telephone Number	:	561-626-4677
Fax Number	:	561-626-6995

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	12/01/2020

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