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General NPI Number Information
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NPI Number | 1962160218
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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 | 12/03/2021
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Last Update Date | 12/05/2021
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Provider Practice Location Address
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Address Line | 3427 FARR RD STE B
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City | FRUITPORT
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State | MI
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Zip | 49415-8854
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Country | US
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Telephone | 231-865-7625
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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 | NAZER ABDEL-FATTAH
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Credential | DO
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Telephone | 313-522-0505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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