Provider Demographics
NPI:1790067015
Name:INTEGRATED PHYSICAL MEDICINE PLLC
Entity Type:Organization
Organization Name:INTEGRATED PHYSICAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:STANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-863-9482
Mailing Address - Street 1:6769 COURTLAND DR NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7242
Mailing Address - Country:US
Mailing Address - Phone:616-863-9482
Mailing Address - Fax:616-863-9486
Practice Address - Street 1:6769 COURTLAND DR NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7242
Practice Address - Country:US
Practice Address - Phone:616-863-9482
Practice Address - Fax:616-863-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty