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General NPI Number Information
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NPI Number | 1417486523
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Entity Type | Organization
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Legal Business Name | INNOVATIVE MEDICINE
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Dates
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Enumeration Date | 06/12/2017
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Last Update Date | 04/18/2024
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Provider Practice Location Address
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Address Line | 3554 PROMENADE PKWY STE H
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City | LAFAYETTE
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State | IN
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Zip | 47909-8418
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Country | US
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Telephone | 765-471-1100
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Fax | 765-471-1009
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Provider Business Mailing Address
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Address Line | 3554 PROMENADE PKWY STE H
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City | LAFAYETTE
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State | IN
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Zip | 47909-8418
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Country | US
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Telephone | 765-471-1100
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Fax | 765-471-1009
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | JACQUELINE SNYDER
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Credential |
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Telephone | 765-413-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207QB0002X
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Taxonomy Name | Obesity Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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