Basic Information
| Provider Information | |||||||||
| NPI: | 1144291923 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERVENTIONAL THERAPEUTICS INSTITUTE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLEARWAY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 DEFENSE HWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555277246 | ||||||||
| FaxNumber: | 8338101165 | ||||||||
| Practice Location | |||||||||
| Address1: | 5102 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555277246 | ||||||||
| FaxNumber: | 8555277246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | KACEY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8507916895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1241 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.