MEDICARE: INTEGRA CONCIERGE MEDICINE LLC

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	202D00000X	Integrative Medicine Physician

General Provider Information

NPI Number	:	1992673305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRA CONCIERGE MEDICINE LLC

Provider Business Mailing Address
First Line	:	10175 FORTUNE PKWY UNIT 204
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6748
Country	:	US
Telephone Number	:	904-619-3609
Fax Number	:	904-900-2225

Provider Business Practice Location Address
First Line	:	10175 FORTUNE PKWY UNIT 204
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6748
Country	:	US
Telephone Number	:	904-619-3609
Fax Number	:	904-900-2225

Authorized Official
Title or Position	:	CEO
Name	:	DR. PAUL BUSSE
Credential	:	MD
Telephone Number	:	904-619-3609

Provider Enumeration Date	:	10/27/2025
Last Update Date	:	10/27/2025

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