Healthcare Provider Details

I. General information

NPI: 1467216366
Provider Name (Legal Business Name): INTEGRATED MEDICAL HEALTH WELLNESS P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E CENTRAL AVE
PEARL RIVER NY
10965-2543
US

IV. Provider business mailing address

2005 PALMER AVE # 1050
LARCHMONT NY
10538-2437
US

V. Phone/Fax

Practice location:
  • Phone: 914-269-8777
  • Fax:
Mailing address:
  • Phone: 914-269-8777
  • Fax: 888-300-0458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAWN K SAMUEL
Title or Position: PRESIDENT
Credential: D.O.
Phone: 914-269-8777