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General NPI Number Information
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NPI Number | 1386359263
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Entity Type | Organization
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Legal Business Name | INTEGRATIVE PEDIATRIC GI AND LIFESTYLE MEDICINE
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Dates
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Enumeration Date | 01/16/2023
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Last Update Date | 01/16/2023
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Provider Practice Location Address
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Address Line | 1123 VILLA LINDE CT STE 38
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City | FLINT
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State | MI
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Zip | 48532-3410
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Country | US
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Telephone | 810-733-7221
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Fax | 810-733-7280
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Provider Business Mailing Address
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Address Line | 7408 WATERFALL DR
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City | GRAND BLANC
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State | MI
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Zip | 48439-7102
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Country | US
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Telephone | 201-931-5713
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RIMA JIBALY
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Credential | MD
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Telephone | 201-931-5713
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0206X
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Taxonomy Name | Pediatric Gastroenterology Physician
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License Number |
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License Number State |
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