Healthcare Provider Details

I. General information

NPI: 1578011219
Provider Name (Legal Business Name): INTEGRATED MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15501 BUSTLETON AVE SUITE #1
PHILADELPHIA PA
19116-1187
US

IV. Provider business mailing address

15501 BUSTLETON AVE SUITE #1
PHILADELPHIA PA
19116-1187
US

V. Phone/Fax

Practice location:
  • Phone: 215-742-7033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT025285
License Number StatePA

VIII. Authorized Official

Name: TOM THOMAS
Title or Position: PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 717-965-7702