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General NPI Number Information
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NPI Number | 1891725743
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Entity Type | Organization
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Legal Business Name | ICC MEDICAL LLC
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Dates
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Enumeration Date | 07/04/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 405 S. L. ROGERS WELLS BLVD
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City | GLASGOW
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State | KY
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Zip | 42141
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Country | US
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Telephone | 270-834-8892
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Fax | 270-834-8899
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Provider Business Mailing Address
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Address Line | 405 S L ROGERS WELLS BLVD
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City | GLASGOW
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State | KY
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Zip | 42141
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Country | US
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Telephone | 270-834-8892
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Fax | 270-834-8899
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROGER TODD WILLIAMS
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Credential | MD
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Telephone | 270-834-8892
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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