Provider Demographics
NPI:1679005557
Name:ICH-EPG ALLIANCE, LLC
Entity type:Organization
Organization Name:ICH-EPG ALLIANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-740-0895
Mailing Address - Street 1:318 MAXWELL RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2063
Mailing Address - Country:US
Mailing Address - Phone:770-740-0895
Mailing Address - Fax:770-740-0896
Practice Address - Street 1:217 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1823
Practice Address - Country:US
Practice Address - Phone:859-239-5008
Practice Address - Fax:859-239-6793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty