Ian Victor Provo

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

149006049 Issued in IL

Practice address

1126 Post Dr
Rockford, IL 61108-4251

Phone

(815) 229-3738

NPI assigned

Sep 26, 2018

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Mr. Ian Victor Provo Professional name

Medicare fee-for-service enrollment

Enrolled in NY, IL2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 2

Specialty

Clinical Social Worker

Education

Other, 1991

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

MCCD Psychiatry Services PLLCGroup PAC ID 4082049036, 206 clinicians

MCCD FL Psychiatry Services PAGroup PAC ID 4880064070, 751 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• MCCD FL Psychiatry Services PA

  dba Talkiatry

  • Psychiatry Physician
  • Jacksonville, FL
  • NPI 1659003457

  IL

  Medicare reassignment Care Compare group NPD
• MCCD Psychiatry Services PLLC

  dba Talkiatry

  • Psychiatry Physician
  • New York, NY
  • NPI 1033750823

  IL

  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1537920000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1537920000000",
    "number": "1235614124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1126 POST DR",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611084251",
            "telephone_number": "815-229-3738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1126 POST DR",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611084251",
            "telephone_number": "815-229-3738"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PROVO",
        "first_name": "IAN",
        "middle_name": "VICTOR",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2018-09-26",
        "last_updated": "2018-09-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "IL",
            "license": "149006049",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "IAN",
            "last_name": "PROVO",
            "middle_name": "VICTOR",
            "prefix": "MR.",
            "credential": "MSW, LCSW",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Hunter Joseph Promer, DO
• Promotion Service LLC
• Sylwia Prorok, OD
• Camilla Provencher, RDN
• Margaret Provenza
• Landon S Pryor, M.D.
• Daniel Psaltis, DC
• Nick D Psaltis, D.C.
• Psychiatric Associates of Rockford SC
• Psychiatric Clinics of Northern Illinois PC

• Clinical Social Worker in Rockford, IL
• Providers in Rockford, IL by specialty
• Clinical Social Worker in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 26, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.