Provider Demographics
NPI:1972592525
Name:IVYREHAB NORTHERN PT, LLC
Entity Type:Organization
Organization Name:IVYREHAB NORTHERN PT, LLC
Other - Org Name:NORTHERN PHYSICAL THERAPY SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-777-8700
Mailing Address - Street 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:
Practice Address - Street 1:31 IDA RED AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-1277
Practice Address - Country:US
Practice Address - Phone:616-887-8152
Practice Address - Fax:616-887-3809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236598Medicare ID - Type UnspecifiedPROVIDER NUMBER