Provider Demographics
NPI:1497813141
Name:MARK IVEY JR MD PC
Entity Type:Organization
Organization Name:MARK IVEY JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:IVEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:928-474-8901
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85547-0129
Mailing Address - Country:US
Mailing Address - Phone:928-474-8901
Mailing Address - Fax:928-474-8947
Practice Address - Street 1:1106 N BEELINE HWY
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-3714
Practice Address - Country:US
Practice Address - Phone:928-474-8901
Practice Address - Fax:928-474-8947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ245341Medicaid
AZ63680Medicare ID - Type Unspecified
AZ245341Medicaid