Provider Demographics
NPI:1568439321
Name:IVEY, TOM (MD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:IVEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 MALSBARY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5644
Mailing Address - Country:US
Mailing Address - Phone:513-366-4488
Mailing Address - Fax:513-366-4480
Practice Address - Street 1:2123 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-651-1180
Practice Address - Fax:513-651-2175
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057125207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
311438871035OtherCARESOURCE
OH0706696Medicaid
285277OtherAMERIGROUP
000000218059OtherANTHEM
KY64860414Medicaid
1800392OtherUHNITED
5712508OtherHUMANA CHOICECARE
2685094OtherAETNA
KY64860414Medicaid
OH0616944Medicare PIN