=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689954240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVA PRIMARY CARE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2011
-----------------------------------------------------
Last Update Date | 07/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 247 CHATEAU DR SW
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35801-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-882-1510
-----------------------------------------------------
Fax | 256-217-5838
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 247 CHATEAU DR SW
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35801-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-882-1510
-----------------------------------------------------
Fax | 256-217-5838
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | BROOKE R UPTAGRAFFT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 256-882-1510
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------