MEDICARE: IM HEALTHCARE PA

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	207R00000X	Internal Medicine Physician	OS 7648	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	74973	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1538116728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IM HEALTHCARE PA

Provider Business Mailing Address
First Line	:	1220 BUSINESS WAY STE 2
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-6073
Country	:	US
Telephone Number	:	239-303-2600
Fax Number	:	239-303-2604

Provider Business Practice Location Address
First Line	:	1220 BUSINESS WAY STE 2
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-6073
Country	:	US
Telephone Number	:	239-303-2600
Fax Number	:	239-303-2604

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JAMES B. MARTIN
Credential	:
Telephone Number	:	239-303-2600

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	10/20/2011

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Directions to “IM HEALTHCARE PA ” Practice Location

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