Premier Surgery Center of the Carolinas, LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

PREMIER SURGERY CENTER OF THE CAROLINAS, LLC

Practice address

1170 Edgewater Corporate Pkwy Ste 106
Indian Land, SC 29707-4607

Phone

(803) 239-4504

NPI assigned

Oct 18, 2024

Last updated

Jun 30, 2025By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Ivan Mac, MDNPI 1689654592

Title

Founding Member

Phone

(704) 254-9099

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in SC

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1023839438. Details of each certification follow.

• CCN 42C0001113 Ambulatory surgical center · Active · Name & address match · Details

Ambulatory surgical center certification: CCN 42C0001113

Legal name

Premier Surgery Center of the Carolinas LLC

Certification status

Active

Provider type (POS)

Ambulatory surgical center

Participating since

Jul 15, 2025

Last certification

Jul 9, 2025

Facility address

1170 Edgewater Corporate Parkway
Fort Mill, SC 29707

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Ivan Mac, MD

  • Ophthalmology Physician
  • Monroe, NC
  • NPI 1689654592

  SC

  Medicare reassignment NPD Authorized official
• Zachary Barton Poole, MD

  • Ophthalmology Physician
  • Clover, SC
  • NPI 1790246585
  Medicare reassignment NPD
• Charles A Blotnick, M.D.

  • Ophthalmology Physician
  • Charlotte, NC
  • NPI 1457320020

  SC

  Medicare reassignment NPD
• Luke Tyler Peterson, M.D.

  • Ophthalmology Physician
  • Matthews, NC
  • NPI 1659698967

  SC

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1729209600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1751241600000",
    "number": "1023839438",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4101 CAMPUS RIDGE RD",
            "city": "MATTHEWS",
            "state": "NC",
            "postal_code": "281055077"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1170 EDGEWATER CORPORATE PKWY STE 106",
            "city": "INDIAN LAND",
            "state": "SC",
            "postal_code": "297074607",
            "telephone_number": "803-239-4504"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIER SURGERY CENTER OF THE CAROLINAS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-10-18",
        "last_updated": "2025-06-30",
        "certification_date": "2025-06-30",
        "status": "A",
        "authorized_official_last_name": "MAC",
        "authorized_official_first_name": "IVAN",
        "authorized_official_title_or_position": "FOUNDING MEMBER",
        "authorized_official_telephone_number": "704-254-9099",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Karen E Preston, CRNP
• Albert Anthony Primavera Jr., DMD
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• Olivia Kathryn Pyles
• QC Investments, LLC (Indian Land Orthodontics)

• Ambulatory Surgical Clinic/Center in Indian Land, SC
• Providers in Indian Land, SC by specialty
• Ambulatory Surgical Clinic/Center in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 30, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.