Provider Demographics
NPI:1982760278
Name:INTEGRATED MEDICAL GROUP
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:THAYER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-692-6700
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0997
Mailing Address - Country:US
Mailing Address - Phone:618-692-6700
Mailing Address - Fax:618-692-6711
Practice Address - Street 1:435 S BUCHANAN ST
Practice Address - Street 2:SUITE B
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2091
Practice Address - Country:US
Practice Address - Phone:618-692-6700
Practice Address - Fax:618-692-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation