Provider Demographics
NPI:1447234521
Name:IVY, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:IVY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-1816
Mailing Address - Country:US
Mailing Address - Phone:717-626-2167
Mailing Address - Fax:717-626-1915
Practice Address - Street 1:562 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-1816
Practice Address - Country:US
Practice Address - Phone:717-626-2167
Practice Address - Fax:717-626-1915
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040279L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5171073OtherAETNA NON-HMO
PA578399OtherAETNA HMO
PAD71478OtherHEALTH ASSURANCE
PAP002302OtherGATEWAY HEALTH PLAN
PA52447 S1QGOtherGEISINGER HEALTH PLAN
PA512264OtherHIGHMARK BLUE SHIELD
PA0011155040001Medicaid
PA01882901OtherCAPITAL BLUE CROSS
PA01882901OtherCAPITAL BLUE CROSS
PAD71478Medicare UPIN