Provider Demographics
NPI:1467924258
Name:THURSTON, IVY L
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:L
Last Name:THURSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-1758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 S STATE ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-1758
Practice Address - Country:US
Practice Address - Phone:231-629-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018286208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501018286Medicaid