Basic Information
| Provider Information | |||||||||
| NPI: | 1891229795 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IPS ASC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GEMINI SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7071 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436172700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198431370 | ||||||||
| FaxNumber: | 4199326779 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 GEMINI PL | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432406109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149877174 | ||||||||
| FaxNumber: | 6149877614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2017 | ||||||||
| LastUpdateDate: | 04/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | MCDOWELL | ||||||||
| AuthorizedOfficialFirstName: | GLADSTONE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4198431370 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.