MEDICARE: EVERNORTH DIRECT HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1063063089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERNORTH DIRECT HEALTH LLC

Provider Business Mailing Address
First Line	:	25600 N NORTERRA DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-8201
Country	:	US
Telephone Number	:	623-277-1190
Fax Number	:

Provider Business Practice Location Address
First Line	:	14311 METROPOLIS AVE STE 102
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4442
Country	:	US
Telephone Number	:	239-768-0127
Fax Number	:	239-768-0671

Authorized Official
Title or Position	:	FINANCIAL ANALYSIS SENIOR MANAGER
Name	:	DEBORAH SUE COOLIDGE
Credential	:
Telephone Number	:	623-277-1170

Provider Enumeration Date	:	09/20/2019
Last Update Date	:	05/03/2021

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