Healthcare Provider Details

I. General information

NPI: 1396797825
Provider Name (Legal Business Name): INTEGRATED GERIATRIC CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 DUDLEY AVE SUITE B
PARKERSBURG WV
26101-2105
US

IV. Provider business mailing address

2801 DUDLEY AVE SUITE B
PARKERSBURG WV
26101-2105
US

V. Phone/Fax

Practice location:
  • Phone: 304-428-1114
  • Fax: 304-428-1135
Mailing address:
  • Phone: 304-428-1114
  • Fax: 304-428-1135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number19159
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: LANCE MCCOY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 304-428-1114