IVY BLACK C-NP
NPI 1104571462
Nurse Practitioner - Family in Kennesaw, GA
About Ivy Black C-np NPPES
Official registry information on file with the National Plan and Provider Enumeration System.
IVY BLACK C-NP (NPI 1104571462) is an individual family provider in Kennesaw, Georgia, licensed in Georgia (RN195496) and active in the NPI registry since February 2022. She is enrolled in Medicare PECOS and is a graduate of Other (2018).
NPPES Registry Identity
Specialties & Licenses
Accepted Insurance
Medicare Participation & PECOS CMS
Medicare enrollment, assignment, billing reassignment, and ordering and referring status from CMS.
Medicare Enrollment Status
Enrolled in Medicare and accepts Medicare assignment
Ivy Black C-np is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.
Medicare Billing Reassignments
2Medicare enrollment records show Ivy Black reassigns Medicare billing to 2 organizations. Each organization bills Medicare for the services this provider delivers there; the nearest is listed first.
Rockville, MD 20854
- Reassigned Medicare billing, Georgia enrollment
- 350 clinicians in this Medicare group
Spring, TX 77373
- Reassigned Medicare billing, Georgia enrollment
- 113 clinicians in this Medicare group
Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.
Physician Visit Costs CMS claims · ZIP area
Typical Medicare office-visit costs in the 30152 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.
Medicare Quality Performance CMS QPP · MIPS
Performance in the CMS Quality Payment Program: the MIPS final score across four weighted categories, and the individual quality measures reported to Medicare.
Other Providers at the Same Location NPPES 8
Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.
KENNESAW, GA 30152
Frequently Asked Questions NPPES & CMS
Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.
What is Ivy Black's NPI number?
The NPI number for Ivy Black is 1104571462. It was assigned to this individual provider in the NPPES registry on February 15, 2022.
Where is Ivy Black located?
Ivy Black practices at 2782 Cobb Pkwy NW, Kennesaw, GA 30152. The listed phone number is (706) 405-1195.
What is Ivy Black's specialty?
The primary specialty registered for this NPI is Nurse Practitioner, specializing in Family, with taxonomy code 363LF0000X.
Is Ivy Black enrolled in Medicare?
Yes. Ivy Black is registered in the Medicare PECOS system and accepts Medicare assignment, which means accepting the Medicare-approved amount as payment in full for covered services.
Which organizations bill Medicare for Ivy Black's services?
According to the CMS Revalidation Reassignment List (October 2026 release), Ivy Black reassigns Medicare benefits to 2 organizations: Minuteclinic LLC (Rockville, MD) and Primary Care PLLC (Spring, TX). Each reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for Ivy Black's services. Reassignment records can lag staffing changes; confirm current arrangements with the organization.
What insurance does Ivy Black accept?
Health plans from CareSource and CareSource (Common Ground Healthcare) list Ivy Black as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.
When was this NPI record last updated?
The NPPES record for Ivy Black was last updated on June 12, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 16 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.
# Ivy Black, C-NP · NPI 1104571462
Family physician in Kennesaw, Georgia. Individual provider, active in the CMS NPPES registry since February 15, 2022.
## Identity
- **NPI:** 1104571462 (Entity type: Individual)
- **Enumerated:** February 15, 2022
- **Primary specialty:** Nurse Practitioner - Family · taxonomy 363LF0000X
- **State license:** RN195496 (Georgia)
- **Sole proprietor:** No
## Practice location
- **Address:** 2782 COBB PKWY NW, Kennesaw, GA 30152-3472
- **Phone:** (706) 405-1195
## Medicare
- **Medicare:** Enrolled (PECOS); accepts Medicare assignment
- **Ordering & referring:** eligible for Part B labs & imaging, durable medical equipment, home health, power mobility devices
- **Bills Medicare through:** 2 organizations under Medicare reassignment (form CMS-855R): Minuteclinic LLC (NPI 1134191836, Rockville, MD); Primary Care PLLC (NPI 1770354763, Spring, TX) · CMS Revalidation Reassignment List, October 2026 release
- **Medical school:** Other, class of 2018
## Record status
- **NPPES last updated:** June 12, 2025
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Source: [NPI Profile](https://npiprofile.com/npi/1104571462) · Data from the CMS NPPES public registry.