Basic Information
| Provider Information | |||||||||
| NPI: | 1790703171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVEY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 247 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394410247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013996167 | ||||||||
| FaxNumber: | 6013996262 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 JEFFERSON ST | ||||||||
| Address2: | SUITE400 | ||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394404306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016497802 | ||||||||
| FaxNumber: | 6014287841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 12509 | MS | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00114933 | 05 | MS | MEDICAID |