Basic Information
| Provider Information | |||||||||
| NPI: | 1952781452 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVACARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30701 LORAIN RD STE A | ||||||||
| Address2: | |||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440706325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
| FaxNumber: | 4407168608 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 SEVERANCE CIR | ||||||||
| Address2: | STE 207 | ||||||||
| City: | CLEVELAND HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441181566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163828874 | ||||||||
| FaxNumber: | 2163827166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | CULLY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4402745000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2375254 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2375254 | 01 | OH | OHIO LICENSE | OTHER |