Provider Demographics
NPI:1932328168
Name:IVY MEDICINE, PC
Entity Type:Organization
Organization Name:IVY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANGHUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-673-1177
Mailing Address - Street 1:PO BOX 2711
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-0559
Mailing Address - Country:US
Mailing Address - Phone:631-673-1177
Mailing Address - Fax:631-489-7035
Practice Address - Street 1:740 VETERANS HWY
Practice Address - Street 2:SUITE 203
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2329
Practice Address - Country:US
Practice Address - Phone:631-673-1177
Practice Address - Fax:631-489-7035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2085782081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWPP501Medicare PIN