Provider Demographics
NPI:1609521681
Name:IMG CLINIC PLLC
Entity Type:Organization
Organization Name:IMG CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-293-8712
Mailing Address - Street 1:610 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3150
Mailing Address - Country:US
Mailing Address - Phone:313-314-0617
Mailing Address - Fax:
Practice Address - Street 1:2510 WADE HAMPTON BLVD STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1168
Practice Address - Country:US
Practice Address - Phone:864-268-8196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty