Healthcare Provider Details

I. General information

NPI: 1053525824
Provider Name (Legal Business Name): COMMUNITY INTEGRATED CARE MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 RHODE ISLAND AVE NE
WASHINGTON DC
20018-1802
US

IV. Provider business mailing address

1615 RHODE ISLAND AVE NE
WASHINGTON DC
20018-1802
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-4511
  • Fax: 202-269-3895
Mailing address:
  • Phone: 202-269-4511
  • Fax: 202-269-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHAEL MCCONNELL
Title or Position: COO
Credential:
Phone: 703-955-0544