Provider Demographics
NPI:1629019062
Name:INTENSIVE CARE CONSORTIUM INC
Entity Type:Organization
Organization Name:INTENSIVE CARE CONSORTIUM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-507-2312
Mailing Address - Street 1:PO BOX 266211
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-6211
Mailing Address - Country:US
Mailing Address - Phone:561-967-4118
Mailing Address - Fax:561-967-3463
Practice Address - Street 1:20900 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180
Practice Address - Country:US
Practice Address - Phone:561-997-0821
Practice Address - Fax:561-997-0849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272561400Medicaid
FL97242OtherBLUE CROSS BLUE SHIELD
FLDE6501OtherRAILROAD MEDICARE
FLK7980Medicare PIN
FLK7980AMedicare PIN
FL97242OtherBLUE CROSS BLUE SHIELD