Basic Information
| Provider Information | |||||||||
| NPI: | 1427290394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMG PT | ||||||||
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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: | 805 N RICHMOND ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | FLEETWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 195221058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109440464 | ||||||||
| FaxNumber: | 6109440465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 03/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | PILLUS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5706225455 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTEGRATED MEDICAL GROUP, P.C. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.