Healthcare Provider Details

I. General information

NPI: 1053926154
Provider Name (Legal Business Name): IDOC VIRTUAL NEURO CRITICAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 EAGLES LANDING PKWY
STOCKBRIDGE GA
30281-5085
US

IV. Provider business mailing address

4635 SOUTHWEST FWY STE 525
HOUSTON TX
77027-7157
US

V. Phone/Fax

Practice location:
  • Phone: 713-913-1422
  • Fax:
Mailing address:
  • Phone: 713-234-4431
  • Fax: 877-712-5707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EVETTE LEWIS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 503-421-5124