Healthcare Provider Details

I. General information

NPI: 1700529120
Provider Name (Legal Business Name): EVERNORTH CARE PROVIDERS - DELAWARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SW MORRISON ST STE 525
PORTLAND OR
97204-3247
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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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