Provider Demographics
NPI:1538261912
Name:IVERSON, RICHARD BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRUCE
Last Name:IVERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:ONE UNIVERSITY CIRCLE
Mailing Address - Street 2:BEU HEALTH CENTER
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455
Mailing Address - Country:US
Mailing Address - Phone:309-298-1888
Mailing Address - Fax:309-298-2188
Practice Address - Street 1:ONE UNIVERSITY CIRCLE
Practice Address - Street 2:BEU HEALTH CENTER
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455
Practice Address - Country:US
Practice Address - Phone:309-298-1888
Practice Address - Fax:309-298-2188
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AI6376710OtherDEA
D09877Medicare UPIN