| Icdoc Llc | |
|
2445 N Westwood Blvd Ste 100 Poplar Bluff MO 63901-2317 | |
| (573) 776-0157 | |
| Not Available |
| Full Name | Icdoc Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 2445 N Westwood Blvd Ste 100, Poplar Bluff, Missouri |
| Authorized Official Name and Position | Shelly Gresham (MEMBER, ADMINISTRATOR) |
| Authorized Official Contact | 5737760157 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Icdoc Llc 2445 N Westwood Blvd Ste 100 Poplar Bluff MO 63901-2317 Ph: (573) 776-0157 | Icdoc Llc 2445 N Westwood Blvd Ste 100 Poplar Bluff MO 63901-2317 Ph: (573) 776-0157 |
| NPI Number | 1629756929 |
|---|---|
| Provider Enumeration Date | 07/06/2023 |
| Last Update Date | 07/06/2023 |
| Medicare PECOS PAC ID | 7719363308 |
|---|---|
| Medicare Enrollment ID | O20230711003862 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629756929 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Shelly Y Gresham |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1063491405 PECOS PAC ID: 1254236995 Enrollment ID: I20031223000646 |
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