Healthcare Provider Details

I. General information

NPI: 1609692045
Provider Name (Legal Business Name): ICU ON DEMAND, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 LITTLE BOOT LN
WESTWOOD MA
02090-2648
US

IV. Provider business mailing address

15 LITTLE BOOT LN
WESTWOOD MA
02090-2648
US

V. Phone/Fax

Practice location:
  • Phone: 104-692-5292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KHALD SOROUR
Title or Position: OWNER
Credential: MD
Phone: 401-692-5292