Provider Demographics
NPI:1831547397
Name:INNOVATION ALLIANCE IPA LLC
Entity type:Organization
Organization Name:INNOVATION ALLIANCE IPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CURT
Authorized Official - Middle Name:
Authorized Official - Last Name:KUBIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-560-1001
Mailing Address - Street 1:691 S GREEN BAY RD # 168
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3153
Mailing Address - Country:US
Mailing Address - Phone:920-209-4440
Mailing Address - Fax:
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-560-1100
Practice Address - Fax:920-560-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherTAX ID NUMBER