Provider Demographics
NPI:1033249404
Name:INTEGRATED MEDICINE GROUP LLC
Entity Type:Organization
Organization Name:INTEGRATED MEDICINE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HEITSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-257-3327
Mailing Address - Street 1:163 NE 102ND AVE
Mailing Address - Street 2:BUILDING V
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4169
Mailing Address - Country:US
Mailing Address - Phone:503-257-3327
Mailing Address - Fax:503-257-3374
Practice Address - Street 1:163 NE 102ND AVE
Practice Address - Street 2:BUILDING V
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4169
Practice Address - Country:US
Practice Address - Phone:503-257-3327
Practice Address - Fax:503-257-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDA9368Medicare PIN
ORR117633Medicare PIN
ORA08050Medicare UPIN