Organization
ICP WEST VIRGINIA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MATTHEW JACKSON (AUTHORIZED OFFICIAL)
(813) 746-3993
Entity
Organization
Contact information
Practice address
500 CHERRY ST, BLUEFIELD, WV 24701-3306
(304) 327-1100
Mailing address
PO BOX 671281, DALLAS, TX 75267-1281
(813) 746-3993
(904) 265-8181
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
—
—
Other
Enumeration date
11/13/2018
Last updated
11/13/2018
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