Ico Primary Care, Llc | |
5700 Se 74th St Ste 100b Oklahoma City OK 73135-1087 | |
(405) 455-5204 | |
Not Available |
Full Name | Ico Primary Care, Llc |
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Speciality | Clinic/Center |
Location | 5700 Se 74th St Ste 100b, Oklahoma City, Oklahoma |
Authorized Official Name and Position | Kevin Penwell (CMO) |
Authorized Official Contact | 4056006869 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Ico Primary Care, Llc 5701 Se 74th St Ste E Oklahoma City OK 73135-1110 Ph: (405) 600-6869 | Ico Primary Care, Llc 5700 Se 74th St Ste 100b Oklahoma City OK 73135-1087 Ph: (405) 455-5204 |
NPI Number | 1568144996 |
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Provider Enumeration Date | 08/04/2023 |
Last Update Date | 08/04/2023 |
Medicare PECOS PAC ID | 6901240910 |
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Medicare Enrollment ID | O20240219000460 |
Identifier | Type | State | Issuer |
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1568144996 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
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261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
Provider Name | Kevin M Penwell |
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Provider Type | Practitioner - Emergency Medicine |
Provider Identifiers | NPI Number: 1841286333 PECOS PAC ID: 8325005580 Enrollment ID: I20041220000487 |
Provider Name | Richard D Brock |
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Provider Type | Practitioner - Family Practice |
Provider Identifiers | NPI Number: 1437131695 PECOS PAC ID: 1658459359 Enrollment ID: I20080422000218 |
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