Healthcare Provider Details

I. General information

NPI: 1316182173
Provider Name (Legal Business Name): IPS OF ST LOUIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8637 DELMAR BLVD
SAINT LOUIS MO
63124-1906
US

IV. Provider business mailing address

PO BOX 864747
ORLANDO FL
32886-4747
US

V. Phone/Fax

Practice location:
  • Phone: 314-983-0303
  • 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 TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: CARL R NOBACK
Title or Position: MEMBER
Credential: MD
Phone: 941-360-1566