1053854208 NPI number — ICCO LLC

Table of content: JAMES JOSEPH MCGANN PA (NPI 1477977312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053854208 NPI number — ICCO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ICCO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053854208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1292 HIGH STREET
Provider Second Line Business Mailing Address:
SUITE 224
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-228-3865
Provider Business Mailing Address Fax Number:
541-654-4693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 NW GOETZ STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-672-4885
Provider Business Practice Location Address Fax Number:
541-672-4782
Provider Enumeration Date:
11/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
PEGGY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
541-672-4885

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DP1360 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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