Provider Demographics
NPI:1568459212
Name:IVEY, ERNEST RACKLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:RACKLEY
Last Name:IVEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:E
Other - Middle Name:RACKLEY
Other - Last Name:IVEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1300 SOUTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985-0009
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-237-2800
Practice Address - Street 1:4346 LAKESHORE LN UNIT 304
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-7169
Practice Address - Country:US
Practice Address - Phone:608-354-3947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44317-0202084F0202X, 2084P0005X, 2084P0800X, 2084P0804X, 209800000X, 2084A0401X
VA01012320742084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC19248OtherMEDICAL LICENSE
GA67772OtherMEDICAL LICENSE
IL036-103584OtherMEDICAL LICENSE
WI44317-20OtherMEDICAL LICENSE
VA0101232074OtherMEDICAL LICENSE
11027179OtherCAQH
WI3428920Medicaid
11027179OtherCAQH