Healthcare Provider Details

I. General information

NPI: 1528297140
Provider Name (Legal Business Name): ISPM ASC AT COVINGTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5303 ADAMS STREET SUITE C
COVINGTON GA
30014
US

IV. Provider business mailing address

PO BOX 11407 DEPT 2338
BIRMINGHAM AL
35246-2338
US

V. Phone/Fax

Practice location:
  • Phone: 770-929-9033
  • Fax: 770-929-9092
Mailing address:
  • Phone: 404-920-4950
  • Fax: 404-920-4959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name: VICTORIA BECK
Title or Position: CFO
Credential:
Phone: 404-920-4950