Healthcare Provider Details

I. General information

NPI: 1881730414
Provider Name (Legal Business Name): INTEGRATED MEDICAL GROUP, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 WEST HIGHWAY 50
O'FALLON IL
62269
US

IV. Provider business mailing address

PO BOX 997
EDWARDSVILLE IL
62025-0997
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-8080
  • Fax: 618-692-6711
Mailing address:
  • Phone: 618-624-8080
  • Fax: 618-692-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID MICHAEL THAYER
Title or Position: OWNER
Credential: DC
Phone: 618-624-8080