Provider Demographics
NPI:1891999108
Name:IMPACT MEDICAL GROUP, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:IMPACT MEDICAL GROUP, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:IFEATU
Authorized Official - Middle Name:
Authorized Official - Last Name:EKELEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-452-1000
Mailing Address - Street 1:5261 E KINGS CANYON RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-4028
Mailing Address - Country:US
Mailing Address - Phone:559-452-1000
Mailing Address - Fax:
Practice Address - Street 1:5261 E KINGS CANYON RD
Practice Address - Street 2:SUITE 107
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-4028
Practice Address - Country:US
Practice Address - Phone:559-452-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care