Provider Demographics
NPI:1689653792
Name:MCIVER, JON I (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:I
Last Name:MCIVER
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 1:10016 INDIGO DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-1206
Mailing Address - Country:US
Mailing Address - Phone:612-751-1414
Mailing Address - Fax:
Practice Address - Street 1:295 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-2400
Practice Address - Country:US
Practice Address - Phone:651-495-6600
Practice Address - Fax:952-883-9677
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42697207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN649666100Medicaid
MN140006832Medicare ID - Type UnspecifiedRAILROAD
H18793Medicare UPIN
MN649666100Medicaid