Provider Demographics
NPI:1174731517
Name:CORPORATE-INDUSTRY MEDICAL GROUP
Entity type:Organization
Organization Name:CORPORATE-INDUSTRY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:F
Authorized Official - Last Name:HEATH
Authorized Official - Suffix:
Authorized Official - Credentials:CLU
Authorized Official - Phone:972-570-8200
Mailing Address - Street 1:4425 W AIRPORT FWY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-5832
Mailing Address - Country:US
Mailing Address - Phone:972-570-8200
Mailing Address - Fax:972-570-8933
Practice Address - Street 1:4425 W AIRPORT FWY
Practice Address - Street 2:SUITE 305
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-5832
Practice Address - Country:US
Practice Address - Phone:972-570-8200
Practice Address - Fax:972-570-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X, 2083P0500X, 208VP0000X, 103G00000X
TXE1580208VP0000X
TXJ91652083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty