Healthcare Provider Details

I. General information

NPI: 1679005557
Provider Name (Legal Business Name): ICH-EPG ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 S 3RD ST
DANVILLE KY
40422-1823
US

IV. Provider business mailing address

318 MAXWELL RD SUITE 500
ALPHARETTA GA
30009-2063
US

V. Phone/Fax

Practice location:
  • Phone: 859-239-5008
  • Fax: 859-239-6793
Mailing address:
  • Phone: 770-740-0895
  • Fax: 770-740-0896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. DAN A. FULLER
Title or Position: PRESIDENT
Credential:
Phone: 770-740-0895