Basic Information
| Provider Information | |||||||||
| NPI: | 1104845361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | I C CARE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 MERCANTILE LN | ||||||||
| Address2: | SUITE #135 | ||||||||
| City: | LARGO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207745380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017739700 | ||||||||
| FaxNumber: | 3017734900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 MERCANTILE LN | ||||||||
| Address2: | SUITE #135 | ||||||||
| City: | LARGO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207745380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017739700 | ||||||||
| FaxNumber: | 3017734900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BONE | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | HERBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3017739700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 174400000X | D31069 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 409341100 | 05 | MD | MEDICAID |