Provider Demographics
NPI:1003864323
Name:INTEGRATED FAMILY MEDICINE, INC.
Entity Type:Organization
Organization Name:INTEGRATED FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WINNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOAZAMPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-818-1477
Mailing Address - Street 1:200 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7515
Mailing Address - Country:US
Mailing Address - Phone:614-793-1980
Mailing Address - Fax:614-793-1985
Practice Address - Street 1:4701 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1950
Practice Address - Country:US
Practice Address - Phone:614-818-1477
Practice Address - Fax:614-642-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-0529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2345215Medicaid
OH2345215Medicaid