Provider Demographics
NPI:1922123587
Name:INTEGRATED HEALTH CARE PROVIDERS
Entity Type:Organization
Organization Name:INTEGRATED HEALTH CARE PROVIDERS
Other - Org Name:ORTHOPEDIC TRAUMA GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:H
Authorized Official - Last Name:GOODE
Authorized Official - Suffix:
Authorized Official - Credentials:PT,MBA
Authorized Official - Phone:304-388-7782
Mailing Address - Street 1:415 MORRIS ST
Mailing Address - Street 2:SUITE #304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:415 MORRIS ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1842
Practice Address - Country:US
Practice Address - Phone:304-388-7782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1248180016Medicare NSC
1248180016Medicare PIN