Provider Demographics
NPI:1487289005
Name:INTEGRATED MEDICAL CLINIC
Entity type:Organization
Organization Name:INTEGRATED MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-509-4091
Mailing Address - Street 1:7404 EXECUTIVE PL STE 100
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-6237
Mailing Address - Country:US
Mailing Address - Phone:240-260-3827
Mailing Address - Fax:240-260-3830
Practice Address - Street 1:7404 EXECUTIVE PL STE 100
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-6237
Practice Address - Country:US
Practice Address - Phone:240-758-1782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-04
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty