Provider Demographics
NPI:1225352966
Name:INNOVATION MD LLC
Entity Type:Organization
Organization Name:INNOVATION MD LLC
Other - Org Name:SAMSAMI MD LLC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMSAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-387-0911
Mailing Address - Street 1:45-1151 KAMEHAMEHA HWY STE C
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3211
Mailing Address - Country:US
Mailing Address - Phone:808-247-7770
Mailing Address - Fax:808-247-7799
Practice Address - Street 1:45-1151 KAMEHAMEHA HWY STE C
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-3211
Practice Address - Country:US
Practice Address - Phone:808-247-7770
Practice Address - Fax:808-247-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD13057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI558835Medicaid