Provider Demographics
NPI:1396879706
Name:IMPACT MEDICAL GROUP
Entity type:Organization
Organization Name:IMPACT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IFEATU
Authorized Official - Middle Name:
Authorized Official - Last Name:EKELEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-452-1000
Mailing Address - Street 1:5261 E KINGS CANYON RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-4028
Mailing Address - Country:US
Mailing Address - Phone:559-452-1000
Mailing Address - Fax:
Practice Address - Street 1:5261 E KINGS CANYON RD
Practice Address - Street 2:SUITE 107
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-4028
Practice Address - Country:US
Practice Address - Phone:559-452-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43177146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF73744Medicare UPIN