Healthcare Provider Details

I. General information

NPI: 1639793912
Provider Name (Legal Business Name): INTEGRATED MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 S PINE ST
ELVERSON PA
19520-9720
US

IV. Provider business mailing address

82 TUNNEL RD
POTTSVILLE PA
17901-3869
US

V. Phone/Fax

Practice location:
  • Phone: 570-624-4777
  • Fax: 570-624-4778
Mailing address:
  • Phone: 570-622-5455
  • Fax: 570-622-5493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY WALSH
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 570-622-5455