Provider Demographics
NPI:1871984336
Name:INTEGRATED MEDICAL GROUP LTD
Entity type:Organization
Organization Name:INTEGRATED MEDICAL GROUP LTD
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,FIAMA,DIPLAC
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 1:8 GINGER CREEK PKWY
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3502
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:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012734111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty