=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720406010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ICON PEDIATRICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2014
-----------------------------------------------------
Last Update Date | 04/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 CHURCH ST SUITE 300
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37203-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-647-8282
-----------------------------------------------------
Fax | 615-647-8283
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 CHURCH ST SUITE 300
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37203-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-647-8282
-----------------------------------------------------
Fax | 615-647-8283
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | EDDIE D HAMILTON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 615-497-4372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 19089
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------