Healthcare Provider Details

I. General information

NPI: 1801551668
Provider Name (Legal Business Name): EVERSIDE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11770 OLIVE BLVD
CREVE COEUR MO
63141-7053
US

IV. Provider business mailing address

4651 CHARLOTTE PARK DR STE 300
CHARLOTTE NC
28217-1916
US

V. Phone/Fax

Practice location:
  • Phone: 866-808-6005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL JOHNSON PATTON
Title or Position: DIRECTOR OF RISK MANAGEMENT
Credential:
Phone: 704-936-5546