Healthcare Provider Details

I. General information

NPI: 1093237125
Provider Name (Legal Business Name): INTEGRATED MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 4TH ST
GADSDEN AL
35901-5217
US

IV. Provider business mailing address

510 S 4TH ST
GADSDEN AL
35901-5217
US

V. Phone/Fax

Practice location:
  • Phone: 256-438-5008
  • Fax: 256-467-4009
Mailing address:
  • Phone: 256-438-5008
  • Fax: 256-467-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32263
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD31385
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD31385
License Number StateAL

VIII. Authorized Official

Name: KARL PETER M UY
Title or Position: DIRECTOR
Credential: MD
Phone: 256-438-5008