Basic Information
| Provider Information | |||||||||
| NPI: | 1336400407 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IPS OF TIDEWATER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 864820 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883373509 | ||||||||
| FaxNumber: | 9413283997 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 GAINSBOROUGH SQ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233201706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575470798 | ||||||||
| FaxNumber: | 7575470145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2012 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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| AuthorizedOfficialLastName: | NOBACK | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8883373509 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.