Provider Demographics
NPI:1699232637
Name:INTEGRATIVE PERFORMANCE MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:INTEGRATIVE PERFORMANCE MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUATTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-659-8889
Mailing Address - Street 1:200 S BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2109
Mailing Address - Country:US
Mailing Address - Phone:618-659-8889
Mailing Address - Fax:618-283-1101
Practice Address - Street 1:200 S BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2109
Practice Address - Country:US
Practice Address - Phone:618-659-8889
Practice Address - Fax:618-283-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty