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General NPI Number Information
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NPI Number | 1023839438
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Entity Type | Organization
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Legal Business Name | PREMIER SURGERY CENTER OF THE CAROLINAS, LLC
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Dates
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Enumeration Date | 10/18/2024
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Last Update Date | 06/30/2025
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Provider Practice Location Address
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Address Line | 1170 EDGEWATER CORPORATE PKWY STE 106
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City | INDIAN LAND
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State | SC
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Zip | 29707-4607
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Country | US
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Telephone | 803-239-4504
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Fax |
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Provider Business Mailing Address
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Address Line | 4101 CAMPUS RIDGE RD
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City | MATTHEWS
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State | NC
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Zip | 28105-5077
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | FOUNDING MEMBER
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Name | DR. IVAN MAC
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Credential | MD
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Telephone | 704-254-9099
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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