1609900364 NPI number — OPTUM PALLIATIVE AND HOSPICE CARE, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609900364 NPI number — OPTUM PALLIATIVE AND HOSPICE CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUM PALLIATIVE AND HOSPICE CARE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVERCARE HOSPICE, INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609900364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15645
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89114-5645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-902-8241
Provider Business Mailing Address Fax Number:
215-902-8809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4875 RIVERSIDE DR STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-1149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-812-9299
Provider Business Practice Location Address Fax Number:
478-912-9270
Provider Enumeration Date:
03/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ENDERLE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
O.
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
860-221-0793

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X , with the licence number: 0011-0296-H , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)