Basic Information
| Provider Information | |||||||||
| NPI: | 1861400756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED HEALTH CARE PROVIDERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FACIAL SURGERY CENTER I | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MORRIS ST STE 304 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887783 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 415 MORRIS ST STE 309 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043883290 | ||||||||
| FaxNumber: | 3043883186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | GOODE | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3043887783 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3810006522 | 05 | WV | MEDICAID |