Provider Demographics
NPI:1922461300
Name:ICM MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ICM MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-855-0556
Mailing Address - Street 1:PO BOX 1698
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90308-1698
Mailing Address - Country:US
Mailing Address - Phone:310-855-0556
Mailing Address - Fax:310-419-9475
Practice Address - Street 1:211 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1412
Practice Address - Country:US
Practice Address - Phone:310-855-0556
Practice Address - Fax:310-419-9475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy