1619423092 NPI number — EVERSIDE HEALTH, LLC

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 1619423092 NPI number — EVERSIDE HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERSIDE HEALTH, LLC
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:
6
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:
1619423092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4651 CHARLOTTE PARK DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28217-1916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N14W23833 STONE RIDGE DR
Provider Second Line Business Practice Location Address:
SUITE 450
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53188-1157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-360-4966
Provider Business Practice Location Address Fax Number:
262-347-0032
Provider Enumeration Date:
08/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PATTON
Authorized Official First Name:
JILL
Authorized Official Middle Name:
JOHNSON
Authorized Official Title or Position:
DIRECTOR OF RISK MANAGEMENT
Authorized Official Telephone Number:
704-936-5546

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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