Provider Demographics
NPI:1245868918
Name:ICH PHYSICIAN GROUP
Entity type:Organization
Organization Name:ICH PHYSICIAN GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-468-3846
Mailing Address - Street 1:361 CARGILE RD
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-3606
Mailing Address - Country:US
Mailing Address - Phone:229-468-3975
Mailing Address - Fax:
Practice Address - Street 1:361 CARGILE RD
Practice Address - Street 2:
Practice Address - City:OCILLA
Practice Address - State:GA
Practice Address - Zip Code:31774-3606
Practice Address - Country:US
Practice Address - Phone:229-468-3975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-30
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care