Provider Demographics
NPI:1558506303
Name:IPS OF FT MYERS LLC
Entity Type:Organization
Organization Name:IPS OF FT MYERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NOBACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-360-1566
Mailing Address - Street 1:5700 MIDNIGHT PASS RD
Mailing Address - Street 2:ST. 4
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34242-3083
Mailing Address - Country:US
Mailing Address - Phone:888-337-3509
Mailing Address - Fax:941-328-3997
Practice Address - Street 1:8255 COLLEGE PKWY
Practice Address - Street 2:ST 100
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5119
Practice Address - Country:US
Practice Address - Phone:888-337-3509
Practice Address - Fax:941-328-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty