Provider Demographics
NPI:1598013955
Name:IVYMC,INC
Entity Type:Organization
Organization Name:IVYMC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WEI WEI
Authorized Official - Middle Name:
Authorized Official - Last Name:NIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-970-1337
Mailing Address - Street 1:91 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2006
Mailing Address - Country:US
Mailing Address - Phone:201-970-1337
Mailing Address - Fax:
Practice Address - Street 1:14022 BEECH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2821
Practice Address - Country:US
Practice Address - Phone:201-970-1337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230713208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty