MEDICARE: EVERSIDE HEALTH-DANVILLE LOGAN AVENUE

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	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician

General Provider Information

NPI Number	:	1215620893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERSIDE HEALTH-DANVILLE LOGAN AVENUE

Provider Business Mailing Address
First Line	:	4651 CHARLOTTE PARK DR STE 300
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-1916
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	603 N LOGAN AVE
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61832-4320
Country	:	US
Telephone Number	:	704-661-1380
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF RISK MANAGEMENT
Name	:	JILL JOHNSON PATTON
Credential	:
Telephone Number	:	704-936-5546

Provider Enumeration Date	:	05/31/2023
Last Update Date	:	05/31/2023

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