Provider Demographics
NPI:1184607426
Name:MCIVOR, JOHN W (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:MCIVOR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11995 SINGLETREE LN
Mailing Address - Street 2:STE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1100
Mailing Address - Fax:952-942-3361
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:952-942-3361
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-01-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY0934212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00387279Medicaid
NY723713Medicare ID - Type UnspecifiedMEDICARE EMPIRE
NY00387279Medicaid
B79172Medicare UPIN