Provider Demographics
NPI:1518930403
Name:IVEY, HENRY (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:IVEY
Suffix:
Gender:M
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:390 S MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1767
Practice Address - Country:US
Practice Address - Phone:540-484-4800
Practice Address - Fax:540-484-4847
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101-026416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005637848Medicaid
VA005623928Medicaid
VA005637830Medicaid
VAC36497Medicare UPIN
VA018031C18Medicare PIN
VA005637830Medicaid
VA005623928Medicaid