Provider Demographics
NPI:1952781452
Name:INNOVACARE LLC
Entity Type:Organization
Organization Name:INNOVACARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:CULLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-274-5000
Mailing Address - Street 1:30701 LORAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-6325
Mailing Address - Country:US
Mailing Address - Phone:440-274-5000
Mailing Address - Fax:440-716-8608
Practice Address - Street 1:5 SEVERANCE CIR
Practice Address - Street 2:STE 207
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1566
Practice Address - Country:US
Practice Address - Phone:216-382-8874
Practice Address - Fax:216-382-7166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH23752542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2375254OtherOHIO LICENSE