NPIMap

Individual provider Active NPI

Mark J Ivanick, MD

  • Pulmonary Disease Physician
  • Elmira, NY
National Provider Identifier
1629065198
Registry record updated Nov 25, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pulmonary Disease PhysicianTaxonomy code 207RP1001X
License
NY139254-1 Issued in NY
Practice address
600 Roe Avenue
Suite 4a
Elmira, NY 14905-1629
Phone
(607) 271-3780
Fax
(607) 271-3894
NPI assigned
Sep 30, 2005
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 25, 2020

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Care Medicine (Internal Medicine) Physician 207RC0200X 139254 NY
Pulmonary Disease Physician 207RP1001X NY139254-1 NY Primary

Addresses

Primary practice location

600 Roe Avenue
Suite 4a
Elmira, NY 14905-1629

Mailing address

571 Saint Josephs Blvd FL 2
Elmira, NY 14901-3230
Phone (607) 271-2050

Other practice location 1

226 W Morris St
Bath, NY 14810-1413
Phone (607) 776-8700

Other identifiers 2

IdentifierTypeStateIssuer
001003160MedicaidPA
00650211MedicaidNY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
NY139254-1NYMDPulmonary Disease Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Pulmonary Associates of the Southern Tier, P.C. Critical Care Medicine Past Accepting new patients
Chemung Medical Services PC Past Accepting new patients
TTPM, Inc Past Accepting new patients
Fort Edward Rescue Squad Inc Past Accepting new patients
Ira Davenport Memorial Hospital, Inc. Past Accepting new patients

Organizations & group practices 5

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.

NPI Registry JSON

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

{
    "created_epoch": "1128038400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1606262400000",
    "number": "1629065198",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "571 SAINT JOSEPHS BLVD FL 2",
            "city": "ELMIRA",
            "state": "NY",
            "postal_code": "149013230",
            "telephone_number": "607-271-2050",
            "fax_number": "607-873-1244"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 ROE AVENUE",
            "address_2": "SUITE 4A",
            "city": "ELMIRA",
            "state": "NY",
            "postal_code": "149051629",
            "telephone_number": "607-271-3780",
            "fax_number": "607-271-3894"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "226 W Morris St",
            "address_purpose": "LOCATION",
            "city": "Bath",
            "state": "NY",
            "postal_code": "148101413",
            "country_code": "US",
            "telephone_number": "607-776-8700",
            "fax_number": "607-776-3679",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "IVANICK",
        "first_name": "MARK",
        "middle_name": "J",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-09-30",
        "last_updated": "2020-11-25",
        "certification_date": "2020-11-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RC0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Critical Care Medicine",
            "state": "NY",
            "license": "139254",
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": "NY",
            "license": "NY139254-1",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "001003160",
            "state": "PA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00650211",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Elmira, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 25, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.