Provider Demographics
NPI:1336160209
Name:INTEGRATED MEDICAL PROFESSIONALS 1, LTD
Entity type:Organization
Organization Name:INTEGRATED MEDICAL PROFESSIONALS 1, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-927-8900
Mailing Address - Street 1:2120 MISTLETOE BLVD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1174
Mailing Address - Country:US
Mailing Address - Phone:817-927-8900
Mailing Address - Fax:817-927-8902
Practice Address - Street 1:2120 MISTLETOE BLVD UNIT 2
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1174
Practice Address - Country:US
Practice Address - Phone:817-927-8900
Practice Address - Fax:817-927-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00185YOtherMEDICARE
TX00186YMedicare ID - Type Unspecified