Basic Information
| Provider Information | |||||||||
| NPI: | 1043784838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED WOUND & OSTOMY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1606 ELDRIDGE DRIVE | ||||||||
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| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193806458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105850857 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N MALIN RD | ||||||||
| Address2: | |||||||||
| City: | BROOMALL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190081429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103560800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2019 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | BOYLE | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6105850857 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | AGPCNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.