Provider Demographics
NPI:1710015235
Name:GREAT COVE INTEGRATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:GREAT COVE INTEGRATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:EUNICE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:717-485-4131
Mailing Address - Street 1:124 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MC CONNELLSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17233-1446
Mailing Address - Country:US
Mailing Address - Phone:717-485-4131
Mailing Address - Fax:717-485-3394
Practice Address - Street 1:124 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MC CONNELLSBURG
Practice Address - State:PA
Practice Address - Zip Code:17233-1446
Practice Address - Country:US
Practice Address - Phone:717-485-4131
Practice Address - Fax:717-485-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067389L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017504800005Medicaid
PA133213OtherHIGHMARK BLUE SHIELD
PA5008657OtherCAPITAL BLUE CROSS
PA5008657OtherCAPITAL BLUE CROSS
PAG93298Medicare UPIN