Provider Demographics
NPI:1750980819
Name:IVY CREEK SPECIALTY CARE
Entity type:Organization
Organization Name:IVY CREEK SPECIALTY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:H
Authorized Official - Last Name:LANGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-283-2542
Mailing Address - Street 1:201 MARIARDEN RD
Mailing Address - Street 2:
Mailing Address - City:DADEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36853-6244
Mailing Address - Country:US
Mailing Address - Phone:256-825-7821
Mailing Address - Fax:
Practice Address - Street 1:201 MARIARDEN RD
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-6244
Practice Address - Country:US
Practice Address - Phone:256-825-7821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty