Healthcare Provider Details

I. General information

NPI: 1285452458
Provider Name (Legal Business Name): IMMUNE CO MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 BRANDON WAY
ROSWELL NM
88201-9799
US

IV. Provider business mailing address

1000 BRICKELL AVE STE 715
MIAMI FL
33131-3047
US

V. Phone/Fax

Practice location:
  • Phone: 512-789-7580
  • Fax:
Mailing address:
  • Phone: 512-789-7580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name: ARIANA THACKER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 512-789-7580