Provider Demographics
NPI:1770235491
Name:IVY MEDICAL PC
Entity Type:Organization
Organization Name:IVY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MINK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-853-9979
Mailing Address - Street 1:3600 ROUTE 66 STE 150
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 ROUTE 66 STE 150
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-2645
Practice Address - Country:US
Practice Address - Phone:415-853-9979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care