1336740976 NPI number — INTEGRATED MEDICAL GROUP, P.C.

Table of content: (NPI 1336740976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336740976 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:
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:
1336740976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
82 TUNNEL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTTSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17901-3869
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:
23 N WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOYERTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19512-1736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-396-5163
Provider Business Practice Location Address Fax Number:
570-624-4778
Provider Enumeration Date:
11/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WALSH
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
570-622-5455

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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