Provider Demographics
NPI:1215433644
Name:IVY SPINE & ORTHOPEDICS, LLC
Entity type:Organization
Organization Name:IVY SPINE & ORTHOPEDICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCLOUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-815-7338
Mailing Address - Street 1:742 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2524
Mailing Address - Country:US
Mailing Address - Phone:850-628-7679
Mailing Address - Fax:850-257-8099
Practice Address - Street 1:742 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2524
Practice Address - Country:US
Practice Address - Phone:765-635-1104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100011207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty