Healthcare Provider Details

I. General information

NPI: 1356541114
Provider Name (Legal Business Name): INTEGRATED HEALTH CARE PROVIDERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE OUTPATIENT CARE CLINIC
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

415 MORRIS ST SUITE 304
CHARLESTON WV
25301-1842
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-8909
  • Fax:
Mailing address:
  • Phone: 304-388-7783
  • Fax: 304-388-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY H. GOODE
Title or Position: PRESIDENT
Credential: PT, MBA
Phone: 304-388-7784