Provider Demographics
NPI:1114602281
Name:INTEGRO CLINIC PLLC
Entity Type:Organization
Organization Name:INTEGRO CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:MASSA SUCCAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-817-8141
Mailing Address - Street 1:6013 KILLARNEY LN S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-1811
Mailing Address - Country:US
Mailing Address - Phone:614-817-8141
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S STE 501
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2116
Practice Address - Country:US
Practice Address - Phone:612-428-4757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty