MEDICARE: INTEGRATED MEDICAL GROUP EASTERN REGION 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	305R00000X	Preferred Provider Organization	P13000057299	FL
2	363L00000X	Nurse Practitioner	P13000057299	FL

General Provider Information

NPI Number	:	1760815922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED MEDICAL GROUP EASTERN REGION INC

Provider Business Mailing Address
First Line	:	9957 MOORINGS DR
Second Line	:	SUITE 204
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-2412
Country	:	US
Telephone Number	:	224-558-9705
Fax Number	:	702-990-7371

Provider Business Practice Location Address
First Line	:	3230 S BUFFALO DR
Second Line	:	SUITE 105
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2505
Country	:	US
Telephone Number	:	224-558-9705
Fax Number	:	702-990-7371

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. AMANDO OBA SILVA JR.
Credential	:
Telephone Number	:	224-558-9705

Provider Enumeration Date	:	08/12/2013
Last Update Date	:	08/12/2013

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