Basic Information
| Provider Information | |||||||||
| NPI: | 1033157441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMG PHYSICIANS,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1375 CORPORATE SQUARE DR | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704583147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374080797 | ||||||||
| FaxNumber: | 9856439808 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 STARBRUSH CIR | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704337208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374080797 | ||||||||
| FaxNumber: | 9858710529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 01/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROMERO | ||||||||
| AuthorizedOfficialFirstName: | MONIQUE | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE TEAM LEAD | ||||||||
| AuthorizedOfficialTelephone: | 3374080797 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03676839 | 05 | MS | MEDICAID | 1448125 | 05 | LA | MEDICAID |