Provider Demographics
NPI:1679508212
Name:INTEGRATED MEDICINE GROUP LLC
Entity Type:Organization
Organization Name:INTEGRATED MEDICINE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEITSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-257-3327
Mailing Address - Street 1:163 NE 102ND AVE BLDG V
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4169
Mailing Address - Country:US
Mailing Address - Phone:503-257-3327
Mailing Address - Fax:503-257-3374
Practice Address - Street 1:163 NE 102ND AVE BLDG V
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4169
Practice Address - Country:US
Practice Address - Phone:503-257-3327
Practice Address - Fax:503-257-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11610208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR117633Medicare PIN