Provider Demographics
NPI:1417486523
Name:INNOVATIVE MEDICINE
Entity Type:Organization
Organization Name:INNOVATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-413-7100
Mailing Address - Street 1:3554 PROMENADE PKWY STE H
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-8418
Mailing Address - Country:US
Mailing Address - Phone:765-471-1100
Mailing Address - Fax:765-471-1009
Practice Address - Street 1:3554 PROMENADE PKWY STE H
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-8418
Practice Address - Country:US
Practice Address - Phone:765-471-1100
Practice Address - Fax:765-471-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1720219702OtherMELISSA GALBRETH LMHC
IN1144372863OtherROBERT CHARLES TURNER MD