Provider Demographics
NPI:1295076552
Name:ILACONE GROUP INCORPORATED
Entity type:Organization
Organization Name:ILACONE GROUP INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:832-345-8141
Mailing Address - Street 1:PO BOX 1537
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77487-1537
Mailing Address - Country:US
Mailing Address - Phone:346-200-5909
Mailing Address - Fax:346-200-5660
Practice Address - Street 1:2121 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-2153
Practice Address - Country:US
Practice Address - Phone:346-907-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
TXP43222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12474223OtherCAQH