Provider Demographics
NPI:1558324194
Name:IMI NEW MEXICO INC
Entity Type:Organization
Organization Name:IMI NEW MEXICO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDVOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-530-0800
Mailing Address - Street 1:1 MCBRIDE AND SON CENTER DR
Mailing Address - Street 2:STE 150
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1425
Mailing Address - Country:US
Mailing Address - Phone:636-530-0800
Mailing Address - Fax:636-519-4081
Practice Address - Street 1:1 MCBRIDE AND SON CENTER DR
Practice Address - Street 2:STE 150
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1425
Practice Address - Country:US
Practice Address - Phone:636-530-0800
Practice Address - Fax:636-519-4081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB3026OtherRAILROAD MEDICARE
NM87975734Medicaid
NM87975734Medicaid