MEDICARE: INNOVATIONS WOUND MANAGEMENT, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	E8768	TX
2	208D00000X	General Practice Physician	M1782	TX
3	208D00000X	General Practice Physician	N6545	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0A5999	OTHER	TX	PTAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0A4645	OTHER	TX	PTAN
4	0A4031	OTHER	TX	PTAN
5	TXB101103	OTHER	TX	PTAN

General Provider Information

NPI Number	:	1083857049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIONS WOUND MANAGEMENT, PA

Provider Business Mailing Address
First Line	:	1234 WAGNER ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-3719
Country	:	US
Telephone Number	:	713-868-3301
Fax Number	:	713-868-4817

Provider Business Practice Location Address
First Line	:	1234 WAGNER ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-3719
Country	:	US
Telephone Number	:	713-868-3301
Fax Number	:	713-868-4817

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MS. MOIRA HAYES
Credential	:	MHA, RRT, CHT
Telephone Number	:	713-301-5707

Provider Enumeration Date	:	04/07/2009
Last Update Date	:	10/27/2010

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Directions to “INNOVATIONS WOUND MANAGEMENT, PA ” Practice Location

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