Provider Demographics
NPI:1366262487
Name:IMPACT PHYSICIAN GROUP, LLC
Entity type:Organization
Organization Name:IMPACT PHYSICIAN GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-967-5599
Mailing Address - Street 1:PO BOX 744577
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:844-440-2328
Practice Address - Street 1:5825 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4316
Practice Address - Country:US
Practice Address - Phone:801-475-5254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty