Healthcare Provider Details

I. General information

NPI: 1104845361
Provider Name (Legal Business Name): I C CARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MERCANTILE LN SUITE #135
LARGO MD
20774-5380
US

IV. Provider business mailing address

1100 MERCANTILE LN SUITE #135
LARGO MD
20774-5380
US

V. Phone/Fax

Practice location:
  • Phone: 301-773-9700
  • Fax: 301-773-4900
Mailing address:
  • Phone: 301-773-9700
  • Fax: 301-773-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD31069
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGE HERBERT BONE
Title or Position: OWNER
Credential: M.D.
Phone: 301-773-9700