Provider Demographics
NPI:1568910768
Name:ICT INTERNAL MEDICINE & PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:ICT INTERNAL MEDICINE & PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-260-6363
Mailing Address - Street 1:8710 W 13TH ST N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-6254
Mailing Address - Country:US
Mailing Address - Phone:316-260-6363
Mailing Address - Fax:
Practice Address - Street 1:8710 W 13TH ST N
Practice Address - Street 2:SUITE 102
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-6254
Practice Address - Country:US
Practice Address - Phone:316-260-6363
Practice Address - Fax:316-260-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty