Basic Information
| Provider Information | |||||||||
| NPI: | 1629504220 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPERIAL MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64568 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850824568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184245449 | ||||||||
| FaxNumber: | 8552301466 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 IRVING PL | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184254096 | ||||||||
| FaxNumber: | 3184258438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2017 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | MOSSALLATI | ||||||||
| AuthorizedOfficialFirstName: | DEANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3184254096 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 303623 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.