MEDICARE: EVERNORTH MEDICAL CARE PROVIDERS NEW YORK PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207QA0505X	Adult Medicine Physician
2	207QH0002X	Hospice and Palliative Medicine (Family Medicine) Physician
3	207R00000X	Internal Medicine Physician
4	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician
5	213E00000X	Podiatrist
6	363L00000X	Nurse Practitioner
7	207Q00000X	Family Medicine Physician

General Provider Information

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

Provider Business Mailing Address
First Line	:	730 COOL SPRINGS BLVD STE 500
Second Line	:
City	:	FRANKLIN
State	:	TN
Zip	:	37067-7331
Country	:	US
Telephone Number	:	773-292-4800
Fax Number	:	312-564-4059

Provider Business Practice Location Address
First Line	:	555 BROADHOLLOW RD STE 305
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5018
Country	:	US
Telephone Number	:	773-292-4800
Fax Number	:	312-564-4059

Authorized Official
Title or Position	:	SENIOR PARALEGAL
Name	:	JACQUELINE D LAKES
Credential	:
Telephone Number	:	954-446-0640

Provider Enumeration Date	:	12/08/2014
Last Update Date	:	07/14/2025

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