Provider Demographics
NPI:1306469978
Name:INTEGRATED MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:INTEGRATED MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:205-519-4201
Mailing Address - Street 1:975 9TH AVE SW STE 200
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35022-7839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:975 9TH AVE SW STE 200
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-7839
Practice Address - Country:US
Practice Address - Phone:205-519-4201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
512-26348OtherBLUE CROSS /BLUE SHIELD OF ALABAMA