Provider Demographics
NPI:1467069070
Name:IVY CREEK SPECIALTY CARE
Entity Type:Organization
Organization Name:IVY CREEK SPECIALTY CARE
Other - Org Name:IVY CREEK ANESTHESIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO & AO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER / CEO
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:500 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-1625
Mailing Address - Country:US
Mailing Address - Phone:334-283-2542
Mailing Address - Fax:342-832-3773
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1625
Practice Address - Country:US
Practice Address - Phone:334-283-2542
Practice Address - Fax:342-832-3773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty