Provider Demographics
NPI:1932561495
Name:IVANICS, TOMMY (MD)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:IVANICS
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 1:202 6TH AVE NW
Mailing Address - Street 2:APT. 206
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-2785
Mailing Address - Country:US
Mailing Address - Phone:917-862-8424
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:HENRY FORD HOSPITAL DEPARTMENT OF SURGERY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-3056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program