Basic Information
| Provider Information | |||||||||
| NPI: | 1760036925 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMPACT PHYSICIAN GROUP INDIANA PULMONARY SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 EASTBROOK BND STE 218 | ||||||||
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| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302691546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789675599 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21 EASTBROOK BND STE 218 | ||||||||
| Address2: | |||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302691546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789675599 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2019 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6789675599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.