Basic Information
| Provider Information | |||||||||
| NPI: | 1053695148 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED MEDICAL GROUP, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | IMG PODIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48 TUNNEL RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706225455 | ||||||||
| FaxNumber: | 5706225493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1626 MOUNT HOPE AVE | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179011302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706222230 | ||||||||
| FaxNumber: | 5706225724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2011 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PILLUS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5706225455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTEGRATED MEDICAL GROUP, P.C. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.