Provider Demographics
NPI:1083857049
Name:INNOVATIONS WOUND MANAGEMENT, PA
Entity Type:Organization
Organization Name:INNOVATIONS WOUND MANAGEMENT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MOIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:MHA, RRT, CHT
Authorized Official - Phone:713-301-5707
Mailing Address - Street 1:1234 WAGNER ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-3719
Mailing Address - Country:US
Mailing Address - Phone:713-868-3301
Mailing Address - Fax:713-868-4817
Practice Address - Street 1:1234 WAGNER ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-3719
Practice Address - Country:US
Practice Address - Phone:713-868-3301
Practice Address - Fax:713-868-4817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8768207Q00000X
TXM1782208D00000X
TXN6545208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A5999OtherPTAN
TX2083529-01Medicaid
TX0A4645OtherPTAN
TX0A4031OtherPTAN
TXTXB101103OtherPTAN