Healthcare Provider Details

I. General information

NPI: 1760815922
Provider Name (Legal Business Name): INTEGRATED MEDICAL GROUP EASTERN REGION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 S BUFFALO DR SUITE 105
LAS VEGAS NV
89117-2505
US

IV. Provider business mailing address

9957 MOORINGS DR SUITE 204
JACKSONVILLE FL
32257-2412
US

V. Phone/Fax

Practice location:
  • Phone: 224-558-9705
  • Fax: 702-990-7371
Mailing address:
  • Phone: 224-558-9705
  • Fax: 702-990-7371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberP13000057299
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberP13000057299
License Number StateFL

VIII. Authorized Official

Name: MR. AMANDO OBA SILVA JR.
Title or Position: PRESIDENT
Credential:
Phone: 224-558-9705