MEDICARE: INNOVATIVE FERTILITY OF OHIO, LLC

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	207VE0102X	Reproductive Endocrinology Physician	35.084514	OH

General Provider Information

NPI Number	:	1558776245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE FERTILITY OF OHIO, LLC

Provider Business Mailing Address
First Line	:	3516 MEADOW LN
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45419-1116
Country	:	US
Telephone Number	:	937-293-4111
Fax Number	:

Provider Business Practice Location Address
First Line	:	8087 WASHINGTON VILLAGE DR
Second Line	:	SUITE 120
City	:	WASHINGTON TOWNSHIP
State	:	OH
Zip	:	45458-1840
Country	:	US
Telephone Number	:	937-458-5084
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. LORIE GROLL
Credential	:	PH.D.
Telephone Number	:	937-458-5084

Provider Enumeration Date	:	06/22/2014
Last Update Date	:	06/22/2014

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