Healthcare Provider Details

I. General information

NPI: 1609155357
Provider Name (Legal Business Name): INNOVATIVEMDGROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 SOUTH COBB SUITE 105
SMYRNA GA
30080-6370
US

IV. Provider business mailing address

3390 PEACHTREE RD NE SUITE 450
ATLANTA GA
30326-1157
US

V. Phone/Fax

Practice location:
  • Phone: 678-838-6600
  • Fax: 770-438-1477
Mailing address:
  • Phone: 678-838-6600
  • Fax: 770-438-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number065573
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number052966
License Number StateGA

VIII. Authorized Official

Name: ANDRES JIMENEZ
Title or Position: CEO
Credential: M.D.
Phone: 678-838-6600