Healthcare Provider Details

I. General information

NPI: 1568730018
Provider Name (Legal Business Name): INTEGRATED HEALTH CARE PROVIDERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 LARRY JOE HARLESS DRIVE
GILBERT WV
25621
US

IV. Provider business mailing address

415 MORRIS ST SUITE 304
CHARLESTON WV
25301-1842
US

V. Phone/Fax

Practice location:
  • Phone: 304-664-2500
  • Fax: 304-664-2997
Mailing address:
  • Phone: 304-388-7782
  • Fax: 304-388-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY H. GOODE
Title or Position: PRESIDENT
Credential: MBA
Phone: 304-388-7782