Provider Demographics
NPI:1013963206
Name:IVAN, PEGGY A (PT)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:A
Last Name:IVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 S ORR RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-9111
Mailing Address - Country:US
Mailing Address - Phone:989-695-9282
Mailing Address - Fax:989-695-9283
Practice Address - Street 1:3680 S ORR RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:MI
Practice Address - Zip Code:48623-9111
Practice Address - Country:US
Practice Address - Phone:989-695-9282
Practice Address - Fax:989-695-9283
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004011225100000X
MI406631-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP97408Medicare UPIN
MION77490Medicare ID - Type UnspecifiedPHYSICAL THERAPIST