1720406010 NPI number — ICON PEDIATRICS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720406010 NPI number — ICON PEDIATRICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ICON PEDIATRICS, 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:
1720406010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 CHURCH ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37203-2234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-647-8282
Provider Business Mailing Address Fax Number:
615-647-8283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37203-2234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-647-8282
Provider Business Practice Location Address Fax Number:
615-647-8283
Provider Enumeration Date:
04/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HAMILTON
Authorized Official First Name:
EDDIE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
615-497-4372

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  19089 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3034011 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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