Provider Demographics
NPI:1629065198
Name:IVANICK, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:IVANICK
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 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:600 ROE AVENUE
Practice Address - Street 2:SUITE 4A
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-271-3780
Practice Address - Fax:607-271-3894
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139254207RC0200X
NYNY139254-1207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001003160Medicaid
NY00650211Medicaid
NYJ400066820Medicare PIN
NY38789EMedicare ID - Type Unspecified