Provider Demographics
NPI:1548284086
Name:INTEGRACE HEALTH INC
Entity type:Organization
Organization Name:INTEGRACE HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUCKENBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-970-2071
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:7200 THIRD AVE
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-1000
Mailing Address - Country:US
Mailing Address - Phone:410-795-8808
Mailing Address - Fax:
Practice Address - Street 1:7200 3RD AVE
Practice Address - Street 2:
Practice Address - City:SYKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21784-5201
Practice Address - Country:US
Practice Address - Phone:410-795-8808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD126651900Medicaid
040246OtherMD DHMH OFFICE OF HTH CA
MDS238Medicare ID - Type Unspecified