Provider Demographics
NPI:1215534011
Name:IVY SPINE & ORTHOPEDICS, LLC
Entity Type:Organization
Organization Name:IVY SPINE & ORTHOPEDICS, LLC
Other - Org Name:IVY SPINE AND ORTHOPEDICS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-628-7679
Mailing Address - Street 1:2532 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4424
Mailing Address - Country:US
Mailing Address - Phone:850-628-7679
Mailing Address - Fax:850-257-8099
Practice Address - Street 1:2532 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4424
Practice Address - Country:US
Practice Address - Phone:850-628-7679
Practice Address - Fax:850-257-8099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVY SPINE & ORTHOPEDICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-05
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty