Healthcare Provider Details

I. General information

NPI: 1740319284
Provider Name (Legal Business Name): INTEGRA PHYSICIANS URGENT CARE CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12161 MANCHESTER RD
SAINT LOUIS MO
63131-4310
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY ATTN CREDENTIALING DEPARTMENT
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-965-7800
  • Fax:
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberR8E05
License Number StateMO

VIII. Authorized Official

Name: IRWIN S. PLISCO
Title or Position: OWNER
Credential: MD
Phone: 314-579-0339