Provider Demographics
NPI:1376588244
Name:INTEGRITY MEDICAL GROUP, S.C.
Entity Type:Organization
Organization Name:INTEGRITY MEDICAL GROUP, S.C.
Other - Org Name:NEW LONDON EMERGENCY PHYSICIANS. S.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RASOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-982-2491
Mailing Address - Street 1:1370 N. SHAWANO ST
Mailing Address - Street 2:STE A
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-7943
Mailing Address - Country:US
Mailing Address - Phone:920-531-1100
Mailing Address - Fax:920-531-8310
Practice Address - Street 1:1370 N. SHAWANO ST
Practice Address - Street 2:STE A
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-7943
Practice Address - Country:US
Practice Address - Phone:920-531-1100
Practice Address - Fax:920-531-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27767-020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21302700Medicaid
WI21302700Medicaid
WI=========013OtherANTHEM BLUE CROSS
WI21302700Medicaid