Provider Demographics
NPI:1649863986
Name:ICOR LLC
Entity type:Organization
Organization Name:ICOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUDMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZAROV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-715-8034
Mailing Address - Street 1:5926 N SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5926 N SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4618
Practice Address - Country:US
Practice Address - Phone:773-715-8034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty