Healthcare Provider Details

I. General information

NPI: 1265725683
Provider Name (Legal Business Name): CRAIG ANTHONY IMM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W HIGH ST SUITE 1103
LIMA OH
45801-4340
US

IV. Provider business mailing address

121 W HIGH ST SUITE 1103
LIMA OH
45801-4340
US

V. Phone/Fax

Practice location:
  • Phone: 419-228-1506
  • Fax: 419-228-3352
Mailing address:
  • Phone: 419-228-1506
  • Fax: 419-228-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.125136
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: