=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841720315
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERSIDE HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2017
-----------------------------------------------------
Last Update Date | 08/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3413 COLONY BAY
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 779-368-0757
-----------------------------------------------------
Fax | 779-368-0758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4651 CHARLOTTE PARK DR STE 300
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28217-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF RISK MANAGEMENT
-----------------------------------------------------
Name | JILL JOHNSON PATTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-936-5546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------