Provider Demographics
NPI:1366783268
Name:INTERNAL MEDICINE SPECIALISTS MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:INTERNAL MEDICINE SPECIALISTS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MYTHE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAMIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-435-0339
Mailing Address - Street 1:1515 E ALLUVIAL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3832
Mailing Address - Country:US
Mailing Address - Phone:559-435-0339
Mailing Address - Fax:559-435-0853
Practice Address - Street 1:1515 E ALLUVIAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3832
Practice Address - Country:US
Practice Address - Phone:559-435-0339
Practice Address - Fax:559-435-0853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-03
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38222207R00000X
CAG59244207R00000X
CAG37512207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG80217OtherINTERNAL MEDICINE