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General NPI Number Information
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NPI Number | 1427371921
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Entity Type | Organization
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Legal Business Name | I.M.P.A.C.T, MEDGROUP, INC
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Dates
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Enumeration Date | 03/11/2010
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Last Update Date | 10/19/2022
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Provider Practice Location Address
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Address Line | 724 39TH ST W
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City | BRADENTON
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State | FL
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Zip | 34205-2454
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Country | US
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Telephone | 941-303-4120
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Fax | 949-437-3960
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Provider Business Mailing Address
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Address Line | 724 39TH ST W
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City | BRADENTON
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State | FL
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Zip | 34205-2454
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Country | US
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Telephone | 941-303-4120
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Fax | 813-641-9001
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | VIVIAN ROBAINA
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Credential |
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Telephone | 941-303-4120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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