Healthcare Provider Details

I. General information

NPI: 1134698798
Provider Name (Legal Business Name): ICP WEST VIRGINIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CHERRY ST
BLUEFIELD WV
24701-3306
US

IV. Provider business mailing address

PO BOX 671281
DALLAS TX
75267-1281
US

V. Phone/Fax

Practice location:
  • Phone: 304-327-1100
  • Fax:
Mailing address:
  • Phone: 813-746-3993
  • Fax: 904-265-8181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW JACKSON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 813-746-3993