Provider Demographics
NPI:1609155357
Name:INNOVATIVEMDGROUP
Entity Type:Organization
Organization Name:INNOVATIVEMDGROUP
Other - Org Name:DRMAJIMENEZ.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-838-6600
Mailing Address - Street 1:3390 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1157
Mailing Address - Country:US
Mailing Address - Phone:678-838-6600
Mailing Address - Fax:770-438-1477
Practice Address - Street 1:3903 SOUTH COBB
Practice Address - Street 2:SUITE 105
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6370
Practice Address - Country:US
Practice Address - Phone:678-838-6600
Practice Address - Fax:770-438-1477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052966207XS0117X
GA065573208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty