Immune Co Medical Group PA

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

Legal business name

IMMUNE CO MEDICAL GROUP PA

Practice address

2500 Brandon Way
Roswell, NM 88201-9799

Phone

(512) 789-7580

NPI assigned

Sep 27, 2024

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ariana Thacker

Title

Authorized Official

Phone

(512) 789-7580

Specialties & licenses 4

Addresses

Other names 1

• MoldCo Other name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1727395200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1727395200000",
    "number": "1285452458",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1000 BRICKELL AVE STE 715",
            "city": "MIAMI",
            "state": "FL",
            "postal_code": "331313047",
            "telephone_number": "512-789-7580"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2500 BRANDON WAY",
            "city": "ROSWELL",
            "state": "NM",
            "postal_code": "882019799",
            "telephone_number": "512-789-7580"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMMUNE CO MEDICAL GROUP PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-09-27",
        "last_updated": "2024-09-27",
        "certification_date": "2024-09-26",
        "status": "A",
        "authorized_official_last_name": "THACKER",
        "authorized_official_first_name": "ARIANA",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "512-789-7580"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "376K00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse's Aide",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MoldCo",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Internal Medicine Physician in Roswell, NM
• Providers in Roswell, NM by specialty
• Internal Medicine Physician in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.