Provider Demographics
NPI:1962450981
Name:IVEY, MARK JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:IVEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17357 VAN WAGONER RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9702
Mailing Address - Country:US
Mailing Address - Phone:616-847-1009
Mailing Address - Fax:616-847-1607
Practice Address - Street 1:17357 VAN WAGONER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-847-1009
Practice Address - Fax:616-847-1607
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407127207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417961137OtherBCBS BRONSON
MI476475710Medicaid
MI1962450981Medicaid
MIC97618333Medicare PIN
MIA79613Medicare UPIN
MI1962450981Medicaid