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General NPI Number Information
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NPI Number | 1215433644
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Entity Type | Organization
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Legal Business Name | IVY SPINE & ORTHOPEDICS, LLC
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Dates
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Enumeration Date | 04/04/2018
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Last Update Date | 09/07/2021
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Provider Practice Location Address
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Address Line | 742 HARRISON AVE
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City | PANAMA CITY
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State | FL
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Zip | 32401-2524
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Country | US
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Telephone | 765-635-1104
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Fax |
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Provider Business Mailing Address
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Address Line | 742 HARRISON AVE
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City | PANAMA CITY
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State | FL
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Zip | 32401-2524
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Country | US
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Telephone | 850-628-7679
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Fax | 850-257-8099
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Authorized Official
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Title or Position | OWNER
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Name | JAMES C MCLOUGHLIN
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Credential | MD
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Telephone | 850-815-7338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | ME100011
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License Number State | FL
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