Healthcare Provider Details

I. General information

NPI: 1225243785
Provider Name (Legal Business Name): INTEGRATED HEALTH CARE PROVIDERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 TEAYS VALLEY ROAD
HURRICANE WV
25526-9645
US

IV. Provider business mailing address

415 MORRIS STREET SUITE 304
CHARLESTON WV
25301-1853
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-2273
  • Fax: 304-760-9290
Mailing address:
  • Phone: 304-388-7782
  • Fax: 304-388-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number1664
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number1664
License Number StateWV

VIII. Authorized Official

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