Provider Demographics
NPI:1073818787
Name:IVY FAMILY MEDICINE, PLC
Entity Type:Organization
Organization Name:IVY FAMILY MEDICINE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LILY
Authorized Official - Middle Name:WISE
Authorized Official - Last Name:HARGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-466-8363
Mailing Address - Street 1:516 ROOKWOOD PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4734
Mailing Address - Country:US
Mailing Address - Phone:434-466-8363
Mailing Address - Fax:
Practice Address - Street 1:2 BOARS HEAD PL
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4611
Practice Address - Country:US
Practice Address - Phone:434-466-8363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057199261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care