Provider Demographics
NPI:1659429249
Name:ASHLAND INTEGRATIVE CARE PC
Entity Type:Organization
Organization Name:ASHLAND INTEGRATIVE CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:GRUBER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:541-201-3173
Mailing Address - Street 1:PO BOX 1300
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-0058
Mailing Address - Country:US
Mailing Address - Phone:541-201-3173
Mailing Address - Fax:561-427-1393
Practice Address - Street 1:850 SISKIYOU BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2125
Practice Address - Country:US
Practice Address - Phone:541-201-3173
Practice Address - Fax:561-427-1393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050217363LF0000X
OR201050218363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500685278Medicaid
ORR181124Medicare PIN