Provider Demographics
NPI:1699299842
Name:INTEGRATED TELEHEALTH LLC
Entity type:Organization
Organization Name:INTEGRATED TELEHEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-831-0204
Mailing Address - Street 1:1523 OLD VALDOSTA RD STE B
Mailing Address - Street 2:
Mailing Address - City:RAY CITY
Mailing Address - State:GA
Mailing Address - Zip Code:31645-7132
Mailing Address - Country:US
Mailing Address - Phone:877-543-7221
Mailing Address - Fax:877-755-2212
Practice Address - Street 1:1523 OLD VALDOSTA RD STE B
Practice Address - Street 2:
Practice Address - City:RAY CITY
Practice Address - State:GA
Practice Address - Zip Code:31645
Practice Address - Country:US
Practice Address - Phone:877-543-7221
Practice Address - Fax:877-755-2212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATED TELEHEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-31
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG38493Medicaid
GA000616624FMedicaid