MEDICARE: ICEM, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467788208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICEM, LLC

Provider Business Mailing Address
First Line	:	5446 RELIABLE PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60686-0001
Country	:	US
Telephone Number	:	317-472-7317
Fax Number	:	317-962-4903

Provider Business Practice Location Address
First Line	:	340 W 10TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-3082
Country	:	US
Telephone Number	:	317-278-3500
Fax Number	:	317-870-0499

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	CAROL KARP
Credential	:
Telephone Number	:	317-278-3522

Provider Enumeration Date	:	10/29/2009
Last Update Date	:	06/14/2011

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Directions to “ICEM, LLC ” Practice Location

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