Organization
IMAGINE MEDICAL GROUP, PA
Active
Other names
Innovatel Medical
Organization subpart
No
Provider details
NPI number
Authorized official
ROBERT WILSON MD (PRESIDENT)
(814) 392-8679
Entity
Organization
Contact information
Practice address
100 S JUNIPER ST FL 3, PHILADELPHIA, PA 19107-1316
(267) 999-9534
Mailing address
228 PARK AVE S, NEW YORK, NY 10003-1502
(267) 999-9534
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
—
—
2084P0800X
Psychiatry Physician
Primary
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Enumeration date
04/20/2022
Last updated
10/24/2024
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