Provider Demographics
NPI:1245497825
Name:IVEY, BERT S (MD)
Entity type:Individual
Prefix:
First Name:BERT
Middle Name:S
Last Name:IVEY
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 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:820 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2028
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11012590A390200000X
WAMD60217654208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11012590AOtherLICENSE
WA1245497825Medicaid
WA0284385OtherL&I
IN11012590AOtherLICENSE
WAG8920568Medicare PIN