Basic Information
| Provider Information | |||||||||
| NPI: | 1467920124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPACT PHYSICIAN GROUP, ILLINOIS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 EASTBROOK BND STE 218 | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302691546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789675599 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 E SOUTH ST STE F | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605451595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305527166 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2018 | ||||||||
| LastUpdateDate: | 12/31/2019 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6786994977 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/31/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RP1001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.