Basic Information
| Provider Information | |||||||||
| NPI: | 1679005557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICH-EPG ALLIANCE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 318 MAXWELL RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300092063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707400895 | ||||||||
| FaxNumber: | 7707400896 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404221823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592395008 | ||||||||
| FaxNumber: | 8592396793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2017 | ||||||||
| LastUpdateDate: | 05/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | FULLER | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7707400895 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.