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NPI Code Detail

MEDICARE: ICC MEDICAL LLC

MEDICARE: ICC MEDICAL LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LF0000XFamily Nurse Practitioner4074PKY

General Provider Information

NPI Number : 1376730705
Entity Type Code : Organization
Provider Name (Legal Business Name) : ICC MEDICAL LLC
Provider Business Mailing Address
First Line : 405 S L ROGERS WELLS BLVD
Second Line :
City : GLASGOW
State : KY
Zip : 42141-1725
Country : US
Telephone Number : 270-834-8892
Fax Number : 270-834-8899
Provider Business Practice Location Address
First Line : 405 S L ROGERS WELLS BLVD
Second Line :
City : GLASGOW
State : KY
Zip : 42141-1725
Country : US
Telephone Number : 270-834-8892
Fax Number : 270-834-8899
Authorized Official
Title or Position : OWNER
Name : DR. ROGER WILLIAMS
Credential : MD
Telephone Number : 270-834-8892
Provider Enumeration Date : 10/01/2007
Last Update Date : 10/01/2007

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Directions to “ICC MEDICAL LLC ” Practice Location

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