=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609155357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVEMDGROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2011
-----------------------------------------------------
Last Update Date | 09/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3903 SOUTH COBB SUITE 105
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-6370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-838-6600
-----------------------------------------------------
Fax | 770-438-1477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3390 PEACHTREE RD NE SUITE 450
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30326-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-838-6600
-----------------------------------------------------
Fax | 770-438-1477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANDRES JIMENEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 678-838-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 065573
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 052966
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------