Provider Demographics
NPI:1891725743
Name:ICC MEDICAL LLC
Entity Type:Organization
Organization Name:ICC MEDICAL LLC
Other - Org Name:IMMEDIATE CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-834-8892
Mailing Address - Street 1:405 S L ROGERS WELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141
Mailing Address - Country:US
Mailing Address - Phone:270-834-8892
Mailing Address - Fax:270-834-8899
Practice Address - Street 1:405 S. L. ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141
Practice Address - Country:US
Practice Address - Phone:270-834-8892
Practice Address - Fax:270-834-8899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000486204OtherANTHEM BC/BS
KY65945404Medicaid
KY65945404Medicaid
KY65945404Medicaid