Provider Demographics
NPI:1215464334
Name:INTERNATIONAL MEDICAL GROUP INC
Entity type:Organization
Organization Name:INTERNATIONAL MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:VERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-893-6632
Mailing Address - Street 1:14431 VENTURA BLVD
Mailing Address - Street 2:#507
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-0152
Mailing Address - Country:US
Mailing Address - Phone:323-893-6632
Mailing Address - Fax:323-417-4865
Practice Address - Street 1:14431 VENTURA BLVD # 507
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2606
Practice Address - Country:US
Practice Address - Phone:323-893-6632
Practice Address - Fax:323-417-4865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X, 385H00000X
CA532014251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1215464334Medicaid