Provider Demographics
NPI:1760440226
Name:INTEGRATED COMMUNITY CLINICS PA
Entity Type:Organization
Organization Name:INTEGRATED COMMUNITY CLINICS PA
Other - Org Name:COMMUNITY PHYSICIANS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-549-3079
Mailing Address - Street 1:1101-2 N PROGRESS AVENUE
Mailing Address - Street 2:PO BOX 1374
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-1374
Mailing Address - Country:US
Mailing Address - Phone:479-549-3079
Mailing Address - Fax:479-549-3275
Practice Address - Street 1:1101-2 N PROGRESS AVENUE
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-4343
Practice Address - Country:US
Practice Address - Phone:479-549-3079
Practice Address - Fax:479-549-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100747540AMedicaid
AR5C090OtherBCBS
AR135299002Medicaid
AR5C090Medicare ID - Type UnspecifiedGROUP NUMBER
ARCI2710Medicare ID - Type UnspecifiedRR MEDICARE GROUP NUMBER
OK400522014Medicare ID - Type UnspecifiedGROUP NUMBER
AR5C090OtherBCBS