Organization
IMMUNE CO MEDICAL GROUP PA
Active
Organization
IMMUNE CO MEDICAL GROUP PA
Active
Other names
MoldCo
Organization subpart
No
Provider details
NPI number
Authorized official
ARIANA THACKER (AUTHORIZED OFFICIAL)
(512) 789-7580
Entity
Organization
Contact information
Practice address
2500 BRANDON WAY, ROSWELL, NM 88201-9799
(512) 789-7580
Mailing address
1000 BRICKELL AVE STE 715, MIAMI, FL 33131-3047
(512) 789-7580
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
363AM0700X
Medical Physician Assistant
—
—
363LF0000X
Family Nurse Practitioner
—
—
376K00000X
Nurse's Aide
—
—
Other
Enumeration date
09/27/2024
Last updated
09/27/2024
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