Provider Demographics
NPI:1952654741
Name:I CARE MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:I CARE MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RICKELL
Authorized Official - Last Name:WILLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MPAS, PAC
Authorized Official - Phone:208-624-4402
Mailing Address - Street 1:430 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-1425
Mailing Address - Country:US
Mailing Address - Phone:208-624-4402
Mailing Address - Fax:208-624-4409
Practice Address - Street 1:430 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1425
Practice Address - Country:US
Practice Address - Phone:208-624-4402
Practice Address - Fax:208-624-4409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA 519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807122700Medicaid
IDQ37128Medicare UPIN
ID807122700Medicaid