Provider Demographics
NPI:1154440527
Name:IMPERIAL COUNTY PHYSICIANS MEDICAL GROUP
Entity Type:Organization
Organization Name:IMPERIAL COUNTY PHYSICIANS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-824-7000
Mailing Address - Street 1:6760 TOP GUN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4152
Mailing Address - Country:US
Mailing Address - Phone:858-824-7000
Mailing Address - Fax:858-824-7010
Practice Address - Street 1:6760 TOP GUN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4152
Practice Address - Country:US
Practice Address - Phone:858-824-7000
Practice Address - Fax:858-824-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty