MEDICARE: IVY SPINE & ORTHOPEDICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1215534011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVY SPINE & ORTHOPEDICS, LLC

Provider Business Mailing Address
First Line	:	2532 CAPITAL MEDICAL BLVD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-4424
Country	:	US
Telephone Number	:	850-628-7679
Fax Number	:	850-257-8099

Provider Business Practice Location Address
First Line	:	2532 CAPITAL MEDICAL BLVD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-4424
Country	:	US
Telephone Number	:	850-628-7679
Fax Number	:	850-257-8099

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	JENNIFER GATES
Credential	:
Telephone Number	:	850-628-7679

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	09/07/2021

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