Healthcare Provider Details

I. General information

NPI: 1184455438
Provider Name (Legal Business Name): INNOVARE MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 BEACON ST STE 4A
BROOKLINE MA
02446-3806
US

IV. Provider business mailing address

187 RICE RD
WAYLAND MA
01778-2808
US

V. Phone/Fax

Practice location:
  • Phone: 508-654-8496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PING JIN
Title or Position: SECRETARY
Credential: MD
Phone: 774-641-7020