Healthcare Provider Details

I. General information

NPI: 1245503515
Provider Name (Legal Business Name): IPS OF CONYERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SIGMAN RD NE SUITE 120
CONYERS GA
30012-3812
US

IV. Provider business mailing address

PO BOX 864778
ORLANDO FL
32886-0001
US

V. Phone/Fax

Practice location:
  • Phone: 770-760-9360
  • Fax:
Mailing address:
  • Phone: 888-337-3509
  • Fax: 941-328-3997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CARL RICHARDSON NOBACK
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 888-337-3309