Healthcare Provider Details

I. General information

NPI: 1699299842
Provider Name (Legal Business Name): INTEGRATED TELEHEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 OLD VALDOSTA RD STE B
RAY CITY GA
31645
US

IV. Provider business mailing address

1523 OLD VALDOSTA RD STE B
RAY CITY GA
31645-7132
US

V. Phone/Fax

Practice location:
  • Phone: 877-543-7221
  • Fax: 877-755-2212
Mailing address:
  • Phone: 877-543-7221
  • Fax: 877-755-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JON C GIBBS
Title or Position: DIRECTOR
Credential: MD
Phone: 706-831-0204