Healthcare Provider Details

I. General information

NPI: 1609187418
Provider Name (Legal Business Name): ICRC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 S DOBSON RD
CHANDLER AZ
85224-5665
US

IV. Provider business mailing address

PO BOX 6423
CHANDLER AZ
85246-6423
US

V. Phone/Fax

Practice location:
  • Phone: 480-821-2838
  • Fax: 480-398-8080
Mailing address:
  • Phone: 480-821-2838
  • Fax: 480-398-8080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER M KELLOGG
Title or Position: PARTNER
Credential: MD
Phone: 480-821-2838