Provider Demographics
NPI:1922458371
Name:ICCO LLC
Entity Type:Organization
Organization Name:ICCO LLC
Other - Org Name:HARRISBURG MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR HARRISBURG CLINIC
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-998-6750
Mailing Address - Street 1:1292 HIGH ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3238
Mailing Address - Country:US
Mailing Address - Phone:541-641-6053
Mailing Address - Fax:541-485-9987
Practice Address - Street 1:420 SMITH ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:OR
Practice Address - Zip Code:97446
Practice Address - Country:US
Practice Address - Phone:541-995-5266
Practice Address - Fax:541-995-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QP2300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR145612Medicare UPIN