Provider Demographics
NPI:1710110077
Name:IPS OF PUNTA GORDA LLC
Entity Type:Organization
Organization Name:IPS OF PUNTA GORDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
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:PO BOX 864483
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-4483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 EDUCATION WAY
Practice Address - Street 2:
Practice Address - City:PT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1000
Practice Address - Country:US
Practice Address - Phone:941-625-9800
Practice Address - Fax:941-625-3492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty