Healthcare Provider Details

I. General information

NPI: 1043804578
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP PULMONARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 CITY CENTER DR
CARMEL IN
46032-3810
US

IV. Provider business mailing address

21 EASTBROOK BND STE 218
PEACHTREE CITY GA
30269-1546
US

V. Phone/Fax

Practice location:
  • Phone: 463-333-9110
  • Fax:
Mailing address:
  • Phone: 678-967-5599
  • Fax: 260-407-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL MILLER
Title or Position: CEO
Credential:
Phone: 678-967-5599