Healthcare Provider Details

I. General information

NPI: 1033342456
Provider Name (Legal Business Name): IPS OF ST MARY'S LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 LINDSEY LN STE B
KINGSLAND GA
31548-6857
US

IV. Provider business mailing address

PO BOX 864483
ORLANDO FL
32886-4483
US

V. Phone/Fax

Practice location:
  • Phone: 912-673-6896
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CARL R. NOBACK
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 941-360-1566