Basic Information
| Provider Information | |||||||||
| NPI: | 1558506303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IPS OF FT MYERS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 MIDNIGHT PASS RD | ||||||||
| Address2: | ST. 4 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342423083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883373509 | ||||||||
| FaxNumber: | 9413283997 | ||||||||
| Practice Location | |||||||||
| Address1: | 8255 COLLEGE PKWY | ||||||||
| Address2: | ST 100 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339195119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883373509 | ||||||||
| FaxNumber: | 9413283997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2008 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | NOBACK | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9413601566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207LP2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.