Provider Demographics
NPI:1336482462
Name:INNOVATIVE PHYSICIAN ASSOCIATES LLC
Entity Type:Organization
Organization Name:INNOVATIVE PHYSICIAN ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETRAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-220-6432
Mailing Address - Street 1:901 MCCLINTOCK DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0844
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-734-4715
Practice Address - Street 1:901 MCCLINTOCK DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0844
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:630-734-4715
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:METRO INFECTIOUS DISEASE CONSULTANTS,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL41053311302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization