MEDICARE: IMG CLINIC 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
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1609521681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMG CLINIC PLLC

Provider Business Mailing Address
First Line	:	610 W 11TH ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-3150
Country	:	US
Telephone Number	:	313-314-0617
Fax Number	:

Provider Business Practice Location Address
First Line	:	2510 WADE HAMPTON BLVD STE B
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-1168
Country	:	US
Telephone Number	:	864-268-8196
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	TODD FENNEL
Credential	:	MD
Telephone Number	:	864-293-8712

Provider Enumeration Date	:	02/17/2022
Last Update Date	:	02/17/2022

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