Healthcare Provider Details

I. General information

NPI: 1205234291
Provider Name (Legal Business Name): EVERNORTH MEDICAL CARE PROVIDERS NEW YORK PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BROADHOLLOW RD STE 305
MELVILLE NY
11747-5018
US

IV. Provider business mailing address

730 COOL SPRINGS BLVD STE 500
FRANKLIN TN
37067-7331
US

V. Phone/Fax

Practice location:
  • Phone: 773-292-4800
  • Fax: 312-564-4059
Mailing address:
  • Phone: 773-292-4800
  • Fax: 312-564-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JACQUELINE D LAKES
Title or Position: SENIOR PARALEGAL
Credential:
Phone: 954-446-0640