Basic Information
Provider Information | |||||||||
NPI: | 1689160731 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRATED MEDICAL GROUP, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 82 TUNNEL RD | ||||||||
Address2: |   | ||||||||
City: | POTTSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 179013869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5706225455 | ||||||||
FaxNumber: | 5706225493 | ||||||||
Practice Location | |||||||||
Address1: | 700 SCHUYLKILL MANOR RD STE 1 | ||||||||
Address2: |   | ||||||||
City: | POTTSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 179013849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5706225672 | ||||||||
FaxNumber: | 5706226099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2018 | ||||||||
LastUpdateDate: | 07/02/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNT | ||||||||
AuthorizedOfficialFirstName: | CRAIG | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5706225455 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1007751740061 | 05 | PA |   | MEDICAID |