Ilya Ivanov, DO

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

License

025MB8329500 Issued in NJ

Practice address

100 Century Pkwy Ste 350
Mount Laurel, NJ 08054-1149

Phone

(856) 482-9000

Fax

(856) 482-1159

NPI assigned

Sep 5, 2007

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 2

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in NJ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Psychiatry

Education

Rowan University School of Osteopathic Medicine, 2005

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Virtua Medical Group, PAGroup PAC ID 9830222397, 1,678 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Jefferson Stratford Hospital Hospital, Stratford, NJ, CCN 310086

Merit-based Incentive Payment System (MIPS)

Final score

81.15 of 100Reported as group

Quality

62.28

Promoting interoperability

100

Improvement activities

40

Cost

74.89

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: iivanov136214@directvirtua.org

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.

• Virtua Medical Group, PA

  • Family Medicine Physician
  • Marlton, NJ
  • NPI 1649226515
  Medicare reassignment Care Compare group NPD
• Oaks Integrated Care

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Westampton, NJ
  • NPI 1255427647
  Medicare reassignment NPD
• Virtua Medical Group, PA

  • Urgent Care Clinic/Center
  • Moorestown, NJ
  • NPI 1184174849
  NPD
• Virtua Medical Group, PA

  • Orthopaedic Surgery Physician
  • Delran, NJ
  • NPI 1841087988
  NPD
• Kennedy University Hospital Inc.

  • General Acute Care Hospital
  • Stratford, NJ
  • NPI 1386746592
  NPD (past)
• Rowansom Newjersey Institute for Successful Aging-Geriatric Psychiatry

  • Psychiatry Physician
  • Stratford, NJ
  • NPI 1881668846
  NPD (past)
• Rowansom Nmi Osteopathic Manipulative Medicine

  • Neuromusculoskeletal Medicine & OMM Physician
  • Stratford, NJ
  • NPI 1447220611
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Kennedy University Hospital Inc.

  • General Acute Care Hospital
  • Stratford, NJ
  • NPI 1386746592
  Care Compare affiliation

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

{
    "created_epoch": "1188950400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1710374400000",
    "number": "1487848149",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 CENTURY PKWY STE 350",
            "city": "MOUNT LAUREL",
            "state": "NJ",
            "postal_code": "080541149",
            "telephone_number": "856-482-9000",
            "fax_number": "856-482-1159"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 CENTURY PKWY STE 350",
            "city": "MOUNT LAUREL",
            "state": "NJ",
            "postal_code": "080541149",
            "telephone_number": "856-482-9000",
            "fax_number": "856-482-1159"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IVANOV",
        "first_name": "ILYA",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-09-05",
        "last_updated": "2024-03-14",
        "certification_date": "2024-03-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NJ",
            "license": "025MB8329500",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P00772213",
            "state": "NJ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0211699",
            "state": "NJ"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "iivanov136214@directvirtua.org",
            "affiliation": "N",
            "address_1": "100 Century Pkwy Ste 350",
            "city": "Mount Laurel",
            "state": "NJ",
            "country_code": "US",
            "postal_code": "080541149",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Integrated Medication Management LLC
• Integrative Medicine and Biofeedback Clinic
• Integrative Training & Consulting, LLC
• Integrative Wellness and Health LLC
• Intellihealth, Inc.
• Ivyrehab Network, Inc.
• Jack Gold Surgical Appliances, Inc.
• Makayla Jack
• Nicole Jacob, FNLP
• Frances Jean Jacobs, DOULA

• Psychiatry Physician in Mount Laurel, NJ
• Providers in Mount Laurel, NJ by specialty
• Psychiatry Physician in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 14, 2024; 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.