Provider Demographics
NPI:1376600718
Name:INTEGRATED CARE OF GREATER HICKORY, INC
Entity Type:Organization
Organization Name:INTEGRATED CARE OF GREATER HICKORY, INC
Other - Org Name:RUDISILL FAMILY PRACTICE, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CAO-CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BLAKEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RMA
Authorized Official - Phone:828-322-5915
Mailing Address - Street 1:741 5TH ST SW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-3230
Mailing Address - Country:US
Mailing Address - Phone:828-322-5915
Mailing Address - Fax:828-345-0387
Practice Address - Street 1:741 5TH ST SW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-3230
Practice Address - Country:US
Practice Address - Phone:828-322-5915
Practice Address - Fax:828-345-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21863101YA0400X, 101YM0800X, 1041C0700X
207Q00000X, 207QA0401X, 2084A0401X, 251S00000X, 3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No3336C0002XSuppliersPharmacyClinic PharmacyGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8973845Medicaid
NC8902716Medicaid
NC0590Medicare UPIN
NC8902716Medicaid