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General NPI Number Information
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NPI Number | 1144975137
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Entity Type | Organization
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Legal Business Name | IMG CLINIC PLLC
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Dates
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Enumeration Date | 02/17/2022
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Last Update Date | 02/17/2022
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Provider Practice Location Address
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Address Line | 206 BURWASH AVE
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City | SAVOY
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State | IL
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Zip | 61874-9510
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Country | US
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Telephone | 313-314-0617
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Fax |
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Provider Business Mailing Address
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Address Line | 610 W 11TH ST
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-3150
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Country | US
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Telephone | 313-314-0617
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | PHILIP G CONRARDY
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Credential | MD
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Telephone | 414-491-6979
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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