Provider Demographics
NPI:1700273083
Name:INTEGRATED MEDICAL GROUP
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:TARRYN
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-226-1117
Mailing Address - Street 1:2244 E HARMONY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3422
Mailing Address - Country:US
Mailing Address - Phone:970-226-1117
Mailing Address - Fax:970-226-0251
Practice Address - Street 1:2244 E HARMONY RD STE 110
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3422
Practice Address - Country:US
Practice Address - Phone:970-226-1117
Practice Address - Fax:970-226-0251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO207Q00000X, 363L00000X
COCHR.0007229111N00000X
COAPN.0991357-NP363L00000X
COAPN.0010285-NP363L00000X
CO493802081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty