Provider Demographics
NPI:1720406010
Name:ICON PEDIATRICS, LLC
Entity Type:Organization
Organization Name:ICON PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-497-4372
Mailing Address - Street 1:1900 CHURCH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2234
Mailing Address - Country:US
Mailing Address - Phone:615-647-8282
Mailing Address - Fax:615-647-8283
Practice Address - Street 1:1900 CHURCH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2234
Practice Address - Country:US
Practice Address - Phone:615-647-8282
Practice Address - Fax:615-647-8283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19089261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3034011Medicaid
TN3034011Medicaid
TNE06309Medicare UPIN