Basic Information
| Provider Information | |||||||||
| NPI: | 1639407422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED PSYCHIATRIC MEDICINE, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4540 KALAMAZOO AVE SE | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495084625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400238 | ||||||||
| FaxNumber: | 6162857211 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 KALAMAZOO AVE SE | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495084625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400238 | ||||||||
| FaxNumber: | 6162857211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | GRIBBIN | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PSYCHIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 6169400238 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.