Healthcare Provider Details

I. General information

NPI: 1629694476
Provider Name (Legal Business Name): VIRTUAL ICU COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 FIRST STREET
MACON GA
31201-2824
US

IV. Provider business mailing address

560 FIRST STREET
MACON GA
31201-2824
US

V. Phone/Fax

Practice location:
  • Phone: 478-477-9603
  • Fax: 478-744-9552
Mailing address:
  • Phone: 478-477-9603
  • Fax: 478-744-9552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. IYABO F. MURAINA
Title or Position: BUSINESS MANAGER
Credential:
Phone: 478-477-9603