NPIMap

Organization Active NPI

Impact Physician Group, Illinois LLC

  • Internal Medicine Physician
  • Plano, IL
National Provider Identifier
1467920124
Registry record updated Dec 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
IMPACT PHYSICIAN GROUP, ILLINOIS LLC
Practice address
115 E South St Ste F
Plano, IL 60545-1595
Phone
(630) 552-7166
NPI assigned
Nov 10, 2018
Last updated
Dec 19, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 19, 2022

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

Authorized official

Name
Mr. Paul Miller
Title
Ceo
Phone
(678) 967-5599

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207R00000X Primary
Endocrinology, Diabetes & Metabolism PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207RE0101X
Gastroenterology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207RG0100X
Pulmonary Disease PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207RP1001X

Addresses

Primary practice location

115 E South St Ste F
Plano, IL 60545-1595

Mailing address

21 Eastbrook BND Ste 218
Peachtree City, GA 30269-1546
Phone (678) 967-5599

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20181231000524 IL Part B Supplier - Clinic/Group Practice 3870838428 Receives reassigned benefits from 12 practitioners
Practice locations: Edwardsville, IL; Woodridge, IL; Plano, IL

National Provider Directory

National Provider Directory

Locations

1041 Station Dr
Ste B7
Oswego, IL 60543
Phone (630) 551-3666

115 E South St
Ste F
Plano, IL 60545
Phone (630) 551-3666

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1541808000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1671408000000",
    "number": "1467920124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21 EASTBROOK BND STE 218",
            "city": "PEACHTREE CITY",
            "state": "GA",
            "postal_code": "302691546",
            "telephone_number": "678-967-5599"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 E SOUTH ST STE F",
            "city": "PLANO",
            "state": "IL",
            "postal_code": "605451595",
            "telephone_number": "630-552-7166"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT PHYSICIAN GROUP, ILLINOIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-11-10",
        "last_updated": "2022-12-19",
        "certification_date": "2022-12-19",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "PAUL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "678-967-5599",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207RE0101X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RG0100X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Gastroenterology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Plano, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.