Provider Demographics
NPI:1962160218
Name:IMG CLINIC PLLC
Entity type:Organization
Organization Name:IMG CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NAZER
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDEL-FATTAH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-522-0505
Mailing Address - Street 1:610 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3150
Mailing Address - Country:US
Mailing Address - Phone:313-314-0617
Mailing Address - Fax:
Practice Address - Street 1:3427 FARR RD STE B
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-8854
Practice Address - Country:US
Practice Address - Phone:231-865-7625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-03
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty