Provider Demographics
NPI:1215763693
Name:IMPACT PHYSICIAN GROUP, LLC
Entity type:Organization
Organization Name:IMPACT PHYSICIAN GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-967-5599
Mailing Address - Street 1:PO BOX 744577
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4577
Mailing Address - Country:US
Mailing Address - Phone:678-967-5599
Mailing Address - Fax:
Practice Address - Street 1:8835 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-7056
Practice Address - Country:US
Practice Address - Phone:720-643-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPACT PHYSICIAN GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty