=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053926154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDOC VIRTUAL NEURO CRITICAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2020
-----------------------------------------------------
Last Update Date | 08/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1133 EAGLES LANDING PKWY
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-5085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-913-1422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4635 SOUTHWEST FWY STE 525
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77027-7157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-234-4431
-----------------------------------------------------
Fax | 877-712-5707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | EVETTE LEWIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-421-5124
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------