MEDICARE: INTEGRA HEALTHCARE ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	363AM0700X	Medical Physician Assistant
3	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1134723919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRA HEALTHCARE ASSOCIATES

Provider Business Mailing Address
First Line	:	4108 CLEARWATER WAY
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40515-6000
Country	:	US
Telephone Number	:	859-396-3050
Fax Number	:

Provider Business Practice Location Address
First Line	:	4071 TATES CREEK CENTRE DR STE 101
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40517-3063
Country	:	US
Telephone Number	:	859-396-3050
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	ALICIA O GATTERDAM
Credential	:
Telephone Number	:	240-271-8962

Provider Enumeration Date	:	11/23/2020
Last Update Date	:	01/31/2023

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