MEDICARE: INTEGRATED MEDICAL PRACTICE PA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician

General Provider Information

NPI Number	:	1750659322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED MEDICAL PRACTICE PA

Provider Business Mailing Address
First Line	:	PO BOX 269083
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73126-9083
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2710 N JOSEY LN
Second Line	:	SUITE 301
City	:	CARROLLTON
State	:	TX
Zip	:	75007-5400
Country	:	US
Telephone Number	:	214-483-3550
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JERRY HOLUBEC
Credential	:	DO
Telephone Number	:	972-479-1115

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	12/09/2011

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Directions to “INTEGRATED MEDICAL PRACTICE PA ” Practice Location

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