1902791569 NPI number — DIVERGE HEALTH ACO OF HEARTLAND OHIO

Table of content: (NPI 1902791569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902791569 NPI number — DIVERGE HEALTH ACO OF HEARTLAND OHIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERGE HEALTH ACO OF HEARTLAND OHIO
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:
Provider Other Organization Name Type Code:
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:
1902791569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 ADAMS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENCOE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60022-1865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-718-9000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2515 JAY AVE # 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44113-3091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-881-7242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2025

Additional Information

Authorized Official

Authorized Official Last Name:
PANTONE
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
941-718-9000

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com