Provider Demographics
NPI:1588654438
Name:IVINS, RHEA (MD)
Entity Type:Individual
Prefix:
First Name:RHEA
Middle Name:
Last Name:IVINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5809
Mailing Address - Country:US
Mailing Address - Phone:315-734-3161
Mailing Address - Fax:315-734-3411
Practice Address - Street 1:2212 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5809
Practice Address - Country:US
Practice Address - Phone:315-734-3161
Practice Address - Fax:315-734-3411
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172299-12080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01104223Medicaid
NY01104223Medicaid