1366887887 NPI number — INTEGRATED MEDICAL GROUP, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366887887 NPI number — INTEGRATED MEDICAL GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED MEDICAL GROUP, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366887887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
48 TUNNEL RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
POTTSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17901-3875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-622-5455
Provider Business Mailing Address Fax Number:
570-622-5493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2210 RIDGEWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WYOMISSING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19610-1287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-372-0502
Provider Business Practice Location Address Fax Number:
610-372-9554
Provider Enumeration Date:
05/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HUNT
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
570-622-5455

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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