Healthcare Provider Details

I. General information

NPI: 1265327076
Provider Name (Legal Business Name): INTEGRATED MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6155 S GRAND BLVD STE 140
SAINT LOUIS MO
63111-2319
US

IV. Provider business mailing address

6155 S GRAND BLVD STE 140
SAINT LOUIS MO
63111-2319
US

V. Phone/Fax

Practice location:
  • Phone: 314-526-6093
  • Fax:
Mailing address:
  • Phone: 314-526-6093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MITCHELL LIBERMAN
Title or Position: MANAGER
Credential: DC
Phone: 314-374-3408