Provider Demographics
NPI:1164485223
Name:INTERNAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:INTERNAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:GLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-396-0450
Mailing Address - Street 1:8614 BAYMEADOWS WAY
Mailing Address - Street 2:SUITE #100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8236
Mailing Address - Country:US
Mailing Address - Phone:904-396-0450
Mailing Address - Fax:904-346-3662
Practice Address - Street 1:8614 BAYMEADOWS WAY
Practice Address - Street 2:SUITE #100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-8236
Practice Address - Country:US
Practice Address - Phone:904-396-0450
Practice Address - Fax:904-346-3662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77460OtherBCBSFL
FL77460Medicare ID - Type Unspecified