1073593190 NPI number — MICHELE R IVANS MSPT

Table of content: MICHELE R IVANS MSPT (NPI 1073593190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073593190 NPI number — MICHELE R IVANS MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVANS
Provider First Name:
MICHELE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073593190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
942 ROSE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80807-1815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-346-6050
Provider Business Mailing Address Fax Number:
719-346-5509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 NW PRAIRIE VIEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLATTE CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64079-7627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-858-3250
Provider Business Practice Location Address Fax Number:
816-858-3253
Provider Enumeration Date:
01/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2005003641 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 11-03404 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 35214014 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".