Basic Information
| Provider Information | |||||||||
| NPI: | 1922096049 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE PHYSICIAN SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 FRANK B MURRAY ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011031106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133016019 | ||||||||
| FaxNumber: | 4133632857 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 PAGE BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133495063 | ||||||||
| FaxNumber: | 4133632857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAHDUL | ||||||||
| AuthorizedOfficialFirstName: | ADNAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CEO/OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4133016019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 9721690 | 05 | MA | MEDICAID | M18224 | 01 | MA | BLUE CROSS | OTHER | 30214102 | 05 | NH | MEDICAID | 110068493C | 05 | MA | MEDICAID |