Basic Information
| Provider Information | |||||||||
| NPI: | 1861693194 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED HEALTH CARE PROVIDERS, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEALTHPLUS URGENT CARE LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MORRIS ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887783 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4602 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049254777 | ||||||||
| FaxNumber: | 3049254780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOODE | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3043887783 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 6702025 005 | 05 | WV | MEDICAID |