Provider Demographics
NPI:1558605204
Name:ISPM ASC AT COVINGTON, LLC
Entity Type:Organization
Organization Name:ISPM ASC AT COVINGTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-929-9033
Mailing Address - Street 1:PO BOX 935100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5100
Mailing Address - Country:US
Mailing Address - Phone:678-729-8590
Mailing Address - Fax:678-729-8595
Practice Address - Street 1:5303 ADAMS ST NE STE C
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-6209
Practice Address - Country:US
Practice Address - Phone:678-729-8590
Practice Address - Fax:678-729-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical