Provider Demographics
NPI:1881742369
Name:INTEGRATIVE MEDICINE AND BIOFEEDBACK CLINIC
Entity type:Organization
Organization Name:INTEGRATIVE MEDICINE AND BIOFEEDBACK CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:C. SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD(AM), PHD
Authorized Official - Phone:856-222-9965
Mailing Address - Street 1:813 E GATE DR STE B
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1238
Mailing Address - Country:US
Mailing Address - Phone:856-222-9965
Mailing Address - Fax:856-222-9916
Practice Address - Street 1:813 E GATE DR STE B
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1238
Practice Address - Country:US
Practice Address - Phone:856-222-9965
Practice Address - Fax:856-222-9916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZE0500X, 175F00000X, 175L00000X, 133NN1002X, 246ZE0600X
NJ103TC0700X
NJ25MB05189200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEGGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No175L00000XOther Service ProvidersHomeopathGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty