Provider Demographics
NPI:1720445158
Name:ADVANCED INTEGRATIVE HEALTH GROUP
Entity Type:Organization
Organization Name:ADVANCED INTEGRATIVE HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:DOM, LAC
Authorized Official - Phone:301-806-4433
Mailing Address - Street 1:2401 BRANDERMILL BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1690
Mailing Address - Country:US
Mailing Address - Phone:301-806-4433
Mailing Address - Fax:
Practice Address - Street 1:2401 BRANDERMILL BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1690
Practice Address - Country:US
Practice Address - Phone:301-806-4433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-14
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD479742Medicare PIN