Specialty |
Taxonomy Code | Specialty Code | Provider Type | |
Addiction Medicine |
207QA0401X | 08 | Physician/Family Practice | |
Adult Medicine |
207QA0505X | 08 | Physician/Family Practice | |
Bariatric Medicine |
207QB0002X | 08 | Physician/Family Practice | |
Non-Pharmacy Dispensing Site |
332900000X | 87 | All Other Suppliers |
| NPI Number | 1417486523 |
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| LBN Legal business name | INNOVATIVE MEDICINE | ||||||||
| Authorized official | JACQUELINE SNYDER - (BILLING MANAGER) | ||||||||
| Entity | Organization | ||||||||
| Organization subpart 1 | No | ||||||||
| Enumeration date | 06/12/2017 | ||||||||
| Last updated | 04/18/2024 - About 2 years ago | ||||||||
| Identifiers |
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