Basic Information
| Provider Information | |||||||||
| NPI: | 1033433826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE HEALTH PARTNERS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4802 E RAY RD | ||||||||
| Address2: | STE 23, PMB 289 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803432280 | ||||||||
| FaxNumber: | 4802848406 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 W SOUTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | APACHE JUNCTION | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802373200 | ||||||||
| FaxNumber: | 4802373206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2010 | ||||||||
| LastUpdateDate: | 03/31/2010 | ||||||||
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| AuthorizedOfficialLastName: | VELARDE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4803432280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 22015 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 392689 | 05 | AZ | MEDICAID |