Provider Demographics
NPI:1942211842
Name:IVINS, GREGORY KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:KEITH
Last Name:IVINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26 S HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-2510
Mailing Address - Country:US
Mailing Address - Phone:573-642-0115
Mailing Address - Fax:573-642-4684
Practice Address - Street 1:26 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-2510
Practice Address - Country:US
Practice Address - Phone:573-642-0115
Practice Address - Fax:573-642-4684
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9723207X00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11090OtherBLUE CROSS/BLUE SHIELD
MO431339000652510OtherCHAMPUS
MO224840OtherHEALTHLINK
MO431339000OtherHUMANA
MOA11946OtherMERCY HEALTH PLAN
MO020004558OtherRAILROAD MEDICARE
MO33711OtherGROUP HEALTH PLAN
MO11090OtherBLUE CHOICE
MO1704001OtherUNITED HEALTH CARE
MO201226313Medicaid
MOA11946Medicare UPIN
MO1704001OtherUNITED HEALTH CARE
MO224840OtherHEALTHLINK