Healthcare Provider Details

I. General information

NPI: 1033754569
Provider Name (Legal Business Name): INTEGRATIVE MEDICINE & VIRTUALCARE PLUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5212A KINGS MILLS RD # 529
MASON OH
45040-2319
US

IV. Provider business mailing address

4234 MARBLE RIDGE LN
MASON OH
45040-2175
US

V. Phone/Fax

Practice location:
  • Phone: 614-653-7351
  • Fax:
Mailing address:
  • Phone: 614-653-7351
  • Fax:

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 Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PENG ETHAN WANG
Title or Position: INTERNIST/OWNER
Credential: DO
Phone: 614-653-7351