Healthcare Provider Details

I. General information

NPI: 1609474998
Provider Name (Legal Business Name): INTEGRATED MED GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2781 FREEWAY BLVD STE 160
BROOKLYN CENTER MN
55430-1765
US

IV. Provider business mailing address

2781 FREEWAY BLVD STE 160
BROOKLYN CENTER MN
55430-1765
US

V. Phone/Fax

Practice location:
  • Phone: 763-515-8799
  • Fax: 763-244-8021
Mailing address:
  • Phone: 763-515-8799
  • Fax: 763-244-8021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JASON STADTHER
Title or Position: CEO/OWNER
Credential: DC
Phone: 763-515-8799