Healthcare Provider Details

I. General information

NPI: 1568604791
Provider Name (Legal Business Name): IPS OF ATLANTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11940 ALPHARETTA HWY SUITE 110
ALPHARETTA GA
30009-2003
US

IV. Provider business mailing address

PO BOX 864483
ORLANDO FL
32886-4483
US

V. Phone/Fax

Practice location:
  • Phone: 770-475-8221
  • Fax:
Mailing address:
  • Phone: 941-360-1566
  • Fax: 941-358-9818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: ROGER SPENCER
Title or Position: PRESIDENT
Credential: MD
Phone: 941-360-1566