=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295076552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILACONE GROUP INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2013
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 BUSINESS CENTER DR
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-2153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-907-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1537
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77487-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-200-5909
-----------------------------------------------------
Fax | 346-200-5660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROGER G JOE
-----------------------------------------------------
Credential | MD, MBA
-----------------------------------------------------
Telephone | 832-345-8141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | P4322
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------