Provider Demographics
NPI:1275278574
Name:INTENSIVE CARE CONSORTIUM - MIDWEST, LLC
Entity Type:Organization
Organization Name:INTENSIVE CARE CONSORTIUM - MIDWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-209-1168
Mailing Address - Street 1:PO BOX 748541
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8541
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:
Practice Address - Street 1:550 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4910
Practice Address - Country:US
Practice Address - Phone:316-962-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty