Provider Demographics
NPI:1154097269
Name:INTEGRATED CARE GROUP LLC
Entity Type:Organization
Organization Name:INTEGRATED CARE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:NPP
Authorized Official - Phone:631-209-4255
Mailing Address - Street 1:363 ROUTE 111 STE 107A
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4750
Mailing Address - Country:US
Mailing Address - Phone:631-209-4255
Mailing Address - Fax:
Practice Address - Street 1:363 ROUTE 111 STE 107
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4750
Practice Address - Country:US
Practice Address - Phone:631-209-4255
Practice Address - Fax:631-693-3313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty