Provider Demographics
NPI:1760815922
Name:INTEGRATED MEDICAL GROUP EASTERN REGION INC
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL GROUP EASTERN REGION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:AMANDO
Authorized Official - Middle Name:OBA
Authorized Official - Last Name:SILVA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:224-558-9705
Mailing Address - Street 1:9957 MOORINGS DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-2412
Mailing Address - Country:US
Mailing Address - Phone:224-558-9705
Mailing Address - Fax:702-990-7371
Practice Address - Street 1:3230 S BUFFALO DR
Practice Address - Street 2:SUITE 105
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2505
Practice Address - Country:US
Practice Address - Phone:224-558-9705
Practice Address - Fax:702-990-7371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP13000057299305R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization