Provider Demographics
NPI:1578308862
Name:IMG MEDICAL GROUP MI, P.C.
Entity type:Organization
Organization Name:IMG MEDICAL GROUP MI, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CLINICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KELSI
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:888-760-4266
Mailing Address - Street 1:201 BROAD ST STE 420
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 BROAD ST STE 420
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-2004
Practice Address - Country:US
Practice Address - Phone:888-760-4266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-27
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty