Healthcare Provider Details

I. General information

NPI: 1578308862
Provider Name (Legal Business Name): IMG MEDICAL GROUP MI, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BROAD ST STE 420
STAMFORD CT
06901-2004
US

IV. Provider business mailing address

201 BROAD ST STE 420
STAMFORD CT
06901-2004
US

V. Phone/Fax

Practice location:
  • Phone: 888-760-4266
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KELSI SULLIVAN
Title or Position: VP CLINICAL SERVICES
Credential: PA-C
Phone: 888-760-4266