Provider Demographics
NPI:1932539624
Name:IVEY FAMILY MEDICINE
Entity type:Organization
Organization Name:IVEY FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:IVEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-657-6501
Mailing Address - Street 1:PO BOX 3570
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-7718
Mailing Address - Country:US
Mailing Address - Phone:479-657-6501
Mailing Address - Fax:479-657-6375
Practice Address - Street 1:2905 S WALTON BLVD.
Practice Address - Street 2:SUITE 17
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-7848
Practice Address - Country:US
Practice Address - Phone:479-657-6501
Practice Address - Fax:479-657-6375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-4023261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR52620Medicare PIN