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NPI Code Detail

MEDICARE: INTEGRATED MED GROUP PLLC

MEDICARE: INTEGRATED MED GROUP PLLC
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
1363L00000XNurse Practitioner
2261QM2500XMedical Specialty Clinic/Center

General Provider Information

NPI Number : 1609474998
Entity Type Code : Organization
Provider Name (Legal Business Name) : INTEGRATED MED GROUP PLLC
Provider Business Mailing Address
First Line : 2781 FREEWAY BLVD STE 160
Second Line :
City : BROOKLYN CENTER
State : MN
Zip : 55430-1765
Country : US
Telephone Number : 763-515-8799
Fax Number : 763-244-8021
Provider Business Practice Location Address
First Line : 2781 FREEWAY BLVD STE 160
Second Line :
City : BROOKLYN CENTER
State : MN
Zip : 55430-1765
Country : US
Telephone Number : 763-515-8799
Fax Number : 763-244-8021
Authorized Official
Title or Position : CEO/OWNER
Name : JASON STADTHER
Credential : DC
Telephone Number : 763-515-8799
Provider Enumeration Date : 10/09/2020
Last Update Date : 10/09/2020

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