Healthcare Provider Details

I. General information

NPI: 1033977665
Provider Name (Legal Business Name): DIVERGE HEALTH IPA OF NY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ADAMS AVE
GLENCOE IL
60022-1865
US

IV. Provider business mailing address

500 ADAMS AVE
GLENCOE IL
60022-1865
US

V. Phone/Fax

Practice location:
  • Phone: 941-718-9000
  • Fax:
Mailing address:
  • Phone: 941-718-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: VINCENT PANTONE
Title or Position: CMO
Credential: MD
Phone: 941-917-9000