Provider Demographics
NPI:1538116728
Name:IM HEALTHCARE PA
Entity Type:Organization
Organization Name:IM HEALTHCARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-303-2600
Mailing Address - Street 1:1220 BUSINESS WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6073
Mailing Address - Country:US
Mailing Address - Phone:239-303-2600
Mailing Address - Fax:239-303-2604
Practice Address - Street 1:1220 BUSINESS WAY STE 2
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6073
Practice Address - Country:US
Practice Address - Phone:239-303-2600
Practice Address - Fax:239-303-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 7648207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74973OtherBLUE CROSS BLUE SHIELD
FLG34479Medicare UPIN
FLK6891Medicare ID - Type Unspecified