Provider Demographics
NPI:1982658563
Name:IVILL, DENNIS W (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:IVILL
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 1:804 SOUTH AVE APT D8
Mailing Address - Street 2:
Mailing Address - City:SECANE
Mailing Address - State:PA
Mailing Address - Zip Code:19018-4426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 LANSDOWNE AVE STE 303
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1333
Practice Address - Country:US
Practice Address - Phone:215-334-3869
Practice Address - Fax:215-755-3300
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042916L208100000X
NJ25MA07886000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3740103OtherAETNA
PA0119006000OtherIBC
0425300OtherCIGNA
PAP00201252Medicare PIN
PA0119006000OtherIBC
PA024864GC6Medicare ID - Type Unspecified