=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215140280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED HEALTH CARE PROVIDERS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 PINNELL STREET
-----------------------------------------------------
City | RIPLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-372-9191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 MORRIS ST SUITE 304
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25301-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-388-7783
-----------------------------------------------------
Fax | 304-388-7788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JEFFREY H GOODE
-----------------------------------------------------
Credential | PT, MBA
-----------------------------------------------------
Telephone | 304-388-7783
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------