Healthcare Provider Details

I. General information

NPI: 1225350564
Provider Name (Legal Business Name): IPS OF SOUTH CAROLINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2010
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2536 LENGERS WAY
FORT MILL SC
29707-7126
US

IV. Provider business mailing address

PO BOX 864483
ORLANDO FL
32886-0001
US

V. Phone/Fax

Practice location:
  • Phone: 803-802-9500
  • Fax: 803-802-8499
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: DR. CARL R NOBACK
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 941-360-1566