Healthcare Provider Details

I. General information

NPI: 1679508212
Provider Name (Legal Business Name): INTEGRATED MEDICINE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 NE 102ND AVE BLDG V
PORTLAND OR
97220-4169
US

IV. Provider business mailing address

163 NE 102ND AVE BLDG V
PORTLAND OR
97220-4169
US

V. Phone/Fax

Practice location:
  • Phone: 503-257-3327
  • Fax: 503-257-3374
Mailing address:
  • Phone: 503-257-3327
  • Fax: 503-257-3374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD11610
License Number StateOR

VIII. Authorized Official

Name: MRS. CHRISTY HEITSCH
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 503-257-3327