Healthcare Provider Details

I. General information

NPI: 1407443617
Provider Name (Legal Business Name): ICP PPO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

413 W MONTGOMERY XRD STE 602
SAVANNAH GA
31406-3396
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-8161
  • Fax:
Mailing address:
  • Phone: 912-691-5711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: KELLY MACKEN - MARBLE
Title or Position: PRESIDENT
Credential:
Phone: 218-393-1566