Provider Demographics
NPI:1699700229
Name:INNOVAMED INTERNAL MEDICINE SPECIALISTS SC
Entity type:Organization
Organization Name:INNOVAMED INTERNAL MEDICINE SPECIALISTS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-987-1802
Mailing Address - Street 1:2601 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3110
Mailing Address - Country:US
Mailing Address - Phone:815-987-1802
Mailing Address - Fax:815-987-1806
Practice Address - Street 1:2601 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3110
Practice Address - Country:US
Practice Address - Phone:815-987-1802
Practice Address - Fax:815-987-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208963Medicare ID - Type Unspecified