Healthcare Provider Details

I. General information

NPI: 1487289005
Provider Name (Legal Business Name): INTEGRATED MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7404 EXECUTIVE PL STE 100
LANHAM MD
20706-6237
US

IV. Provider business mailing address

7404 EXECUTIVE PL STE 100
LANHAM MD
20706-6237
US

V. Phone/Fax

Practice location:
  • Phone: 240-758-1782
  • Fax:
Mailing address:
  • Phone: 240-260-3827
  • Fax: 240-260-3830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PAIGE SMITH
Title or Position: PRACTICE ADMINSTRATOR
Credential:
Phone: 301-509-4091