MEDICARE: INTEGRATED HEALTH CARE PROVIDERS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699781294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED HEALTH CARE PROVIDERS, INC.

Provider Business Mailing Address
First Line	:	415 MORRIS ST STE 304
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-1853
Country	:	US
Telephone Number	:	304-388-7782
Fax Number	:	304-388-7788

Provider Business Practice Location Address
First Line	:	830 PENNSYLVANIA AVE STE 302
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25302-3390
Country	:	US
Telephone Number	:	304-388-2950
Fax Number	:	304-388-2951

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEFF GOODE
Credential	:	PT, MBA
Telephone Number	:	304-388-7783

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	11/15/2007

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