Healthcare Provider Details

I. General information

NPI: 1154097269
Provider Name (Legal Business Name): INTEGRATED CARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 08/18/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 ROUTE 111 STE 107
SMITHTOWN NY
11787-4750
US

IV. Provider business mailing address

363 ROUTE 111 STE 107A
SMITHTOWN NY
11787-4750
US

V. Phone/Fax

Practice location:
  • Phone: 631-209-4255
  • Fax: 631-693-3313
Mailing address:
  • Phone: 631-209-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ROSE PETERSON
Title or Position: ADMINISTRATOR
Credential: NPP
Phone: 631-209-4255