Provider Demographics
NPI:1871931741
Name:INTEGRATED MEDICAL GROUP INC
Entity type:Organization
Organization Name:INTEGRATED MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMBULAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-224-9390
Mailing Address - Street 1:8622 RESEDA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4091
Mailing Address - Country:US
Mailing Address - Phone:818-224-9390
Mailing Address - Fax:818-938-1538
Practice Address - Street 1:208 E CARSON ST STE 101
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2762
Practice Address - Country:US
Practice Address - Phone:818-224-9390
Practice Address - Fax:818-938-1538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-12
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3565047363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty