Basic Information
| Provider Information | |||||||||
| NPI: | 1275278574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTENSIVE CARE CONSORTIUM - MIDWEST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 748541 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303748541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 N HILLSIDE ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672144910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169622000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2022 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED SIGNER | ||||||||
| AuthorizedOfficialTelephone: | 6153092065 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.