1275278574 NPI number — INTENSIVE CARE CONSORTIUM - MIDWEST, LLC

Table of content: (NPI 1275278574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275278574 NPI number — INTENSIVE CARE CONSORTIUM - MIDWEST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTENSIVE CARE CONSORTIUM - MIDWEST, 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:
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:
1275278574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 748541
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-8541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-373-7600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 N HILLSIDE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67214-4910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-962-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED SIGNER
Authorized Official Telephone Number:
615-309-2065

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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