MEDICARE: INTEGRATED MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	NV20121441185	NV

General Provider Information

NPI Number	:	1205182292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	3230 S BUFFALO DR STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2506
Country	:	US
Telephone Number	:	702-985-2533
Fax Number	:

Provider Business Practice Location Address
First Line	:	3230 S BUFFALO DR STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2506
Country	:	US
Telephone Number	:	702-985-2533
Fax Number	:	702-253-7288

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARIA LOURDES YUVIENCO PECHO
Credential	:	MS ECO
Telephone Number	:	702-985-2533

Provider Enumeration Date	:	07/27/2012
Last Update Date	:	07/27/2012

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