Provider Demographics
NPI:1861662520
Name:INTEGRATIVE MEDICINE ASSOCIATES PC
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICINE ASSOCIATES PC
Other - Org Name:LIFESCORE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MILGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-455-6100
Mailing Address - Street 1:8899 UNIVERSITY CENTER LN
Mailing Address - Street 2:SUITE 100 SAN DIEGO
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1013
Mailing Address - Country:US
Mailing Address - Phone:858-455-6100
Mailing Address - Fax:858-558-1884
Practice Address - Street 1:8899 UNIVERSITY CENTER LN
Practice Address - Street 2:SUITE 100 SAN DIEGO
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1013
Practice Address - Country:US
Practice Address - Phone:858-455-6100
Practice Address - Fax:858-558-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-09
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47356207R00000X, 207RE0101X, 2083P0901X
CAA43603207RC0000X
CAA35411207V00000X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20747Medicare PIN