Provider Demographics
NPI:1639517410
Name:INTEGRATED MEDICAL PRACTICE
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLUBEC
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-234-4740
Mailing Address - Street 1:4110 FM 407
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-7269
Mailing Address - Country:US
Mailing Address - Phone:940-455-2336
Mailing Address - Fax:940-455-7359
Practice Address - Street 1:4110 FM 407
Practice Address - Street 2:SUITE 200
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-7269
Practice Address - Country:US
Practice Address - Phone:940-455-2336
Practice Address - Fax:940-455-7359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE20221174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE20221Medicare UPIN