Provider Demographics
NPI:1265087472
Name:INNOVISTA PROVIDER GROUP TEXAS PA
Entity type:Organization
Organization Name:INNOVISTA PROVIDER GROUP TEXAS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-720-7042
Mailing Address - Street 1:PO BOX 8150
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-8150
Mailing Address - Country:US
Mailing Address - Phone:844-665-4827
Mailing Address - Fax:855-485-0093
Practice Address - Street 1:2610 NORTH MASON ROAD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449
Practice Address - Country:US
Practice Address - Phone:305-470-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVISTA PROVIDER GROUP TEXAS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-05
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty