Provider Demographics
NPI:1235659319
Name:IMC-EASTERN SHORE FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:IMC-EASTERN SHORE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-435-1361
Mailing Address - Street 1:PO BOX 2226
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36652-2226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27961 HIGHWAY 98
Practice Address - Street 2:SUITE 14
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526
Practice Address - Country:US
Practice Address - Phone:251-626-1175
Practice Address - Fax:251-626-1507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty