Icp PPO, LLC

Primary specialty

Preferred Provider OrganizationTaxonomy code 305R00000X

Legal business name

ICP PPO, LLC

Practice address

211 N Eddy St
South Bend, IN 46617-2808

Phone

(574) 234-8161

NPI assigned

Dec 22, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kelly Macken - Marble

Title

President

Phone

(218) 393-1566

Specialties & licenses 2

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1608595200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1608595200000",
    "number": "1407443617",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "413 W MONTGOMERY XRD STE 602",
            "city": "SAVANNAH",
            "state": "GA",
            "postal_code": "314063396",
            "telephone_number": "912-691-5711"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "211 N EDDY ST",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466172808",
            "telephone_number": "574-234-8161"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ICP PPO, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-12-22",
        "last_updated": "2020-12-22",
        "certification_date": "2020-12-22",
        "status": "A",
        "authorized_official_last_name": "MACKEN - MARBLE",
        "authorized_official_first_name": "KELLY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "218-393-1566"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Preferred Provider Organization in South Bend, IN
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.